Evaluation of menstrual irregularities after COVID-19 vaccination: Results of the MECOVAC survey
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Antonio Simone Laganà
, Giovanni Veronesi
, Fabio Ghezzi
, Marco Mario Ferrario
, Antonella Cromi
, Mariano Bizzarri
, Simone Garzon
and Marco Cosentino
Abstract
We investigated menstrual irregularities after the first and second doses of the COVID-19 vaccine. Women answered a customised online questionnaire (ClinicalTrial.gov ID: NCT05083065) aimed to assess the vaccine type, the phase of the menstrual cycle during which the vaccine was administered, the occurrence of menstrual irregularities after the first and second doses, and how long this effect lasted. We excluded women with gynaecological and non-gynaecological diseases, undergoing hormonal and non-hormonal treatments, in perimenopause or menopause, as well as those who had irregular menstrual cycles in the last 12 months before vaccine administration. According to our data analysis, approximately 50–60% of reproductive-age women who received the first dose of the COVID-19 vaccine reported menstrual cycle irregularities, regardless of the type of administered vaccine. The occurrence of menstrual irregularities seems to be slightly higher (60–70%) after the second dose. Menstrual irregularities after both the first and second doses of the vaccine were found to self-resolve in approximately half the cases within two months. Based on these results, we suggest to consider these elements during the counselling of women who receive the COVID-19 vaccine, letting them know about the potential occurrence of temporary and self-limiting menstrual cycle irregularities in the subsequent month(s).
1 Introduction
Italy was one of the first countries where the COVID-19 pandemic started [1], after the initial spread in Wuhan, China [2]. Lombardy and Veneto, as well as other northern areas of Italy, had the highest morbidity and mortality rates since they were suddenly hit by the new virus, whose biological and clinical effects were yet unknown [3]. Among the potential strategies to counteract the pandemic, since January 2021, Italy started a campaign to increase the vaccination rate of healthcare providers, fragile patients, and general population as much as possible [4]. Four different vaccines were used: Comirnaty (Pfizer-BioNTech), Spikevax (Moderna), and Vaxzevria (AstraZeneca), which could be administered for the first and second doses, and Janssen (Johnson & Johnson) in a single administration. In addition, since 15 October 2021, the Italian government required to have a valid European Digital COVID Certificate (EDCC) for all productive activities and to work [5], and this further increased the vaccination rate among the general population, similar to other countries [6]. Notably, data from the EudraVigilance European database (23 June 2021) show in young adult (18–64 years old) and older (≥65 years old) recipients a higher number of severe adverse events caused by venous blood clots, haemorrhage, thromboembolic disease, and arterial events, including myocardial infarction and stroke, with the use of virus-based COVID-19 vaccines than other types of vaccines [7].
From our local perspective, we started to notice an increased number of outpatient visits for menstrual irregularities and abnormal uterine bleeding in women who received the COVID-19 vaccine. Interestingly, although the UK’s Medicines and Healthcare products Regulatory Agency (MHRA) stated that the evaluation of yellow card surveillance reports does not support a link between changes in menstrual periods and COVID-19 vaccines, a potential link has been recently suggested and solicited further investigation [8]. In this scenario, the National Institutes of Health (NIH) recently awarded one-year supplemental grants, totalling $1.67 million, to five institutions for exploring potential links between COVID-19 vaccination and menstrual changes [9], since some women have reported experiencing irregular or missing menstrual periods, bleeding that is heavier than usual, and other menstrual changes after receiving COVID-19 vaccines. Interestingly, in a recent study on women of childbearing age, approximately 25% of patients infected with COVID-19 experienced menstrual disruption [10]. In addition, women infected with COVID-19 were found to have a decrease in menstruation duration compared with their own pre-pandemic data: in particular, Demir et al. found a positive correlation between the stress and anxiety associated with COVID-19 and menstrual cycle dysregulations [11].
Based on these elements, we decided to investigate the occurrence of menstrual irregularities and abnormal uterine bleeding after the first and second doses of the COVID-19 vaccine, correlate these cases to the type of vaccine administered, and evaluate how long this effect lasted.
2 Methods
2.1 Setting, data sources, and study population
We designed a customised pilot questionnaire (menstruation after COVID vaccine, MECOVAC) consisting of 26 multiple-choice questions. The first 13 items aimed to assess age, body mass index, concurrent gynaecological and non-gynaecological disorders, use hormonal and non-hormonal pharmacological treatments, number of previous pregnancies and abortions, reproductive or (peri)menopausal status, and type of COVID-19 vaccine used for the first and second doses (single in case of Janssen by Johnson & Johnson). The following three questions (items 14–16) assessed the frequency, length, and quantity of the menstrual cycles before the first dose of the COVID-19 vaccine (single in the case of Janssen by Johnson & Johnson). The following five questions (items 17–21) assessed the phase of the menstrual cycle in which the first dose of the COVID-19 vaccine (single in the case of Janssen by Johnson & Johnson) was administered, the frequency, length, and quantity of the menstrual cycle after the administration, and how long this effect lasted in case of menstrual cycle irregularities and/or abnormal uterine bleeding. The last five questions (items 22–26) assessed the phase of the menstrual cycle in which the second dose of the COVID-19 vaccine (not applicable in case of the single dose of Janssen by Johnson & Johnson) was administered, the frequency, length, and quantity of the menstrual cycle after the administration, and how long this effect lasted in case of menstrual cycle irregularities and/or abnormal uterine bleeding.
In women of reproductive age who were not using hormonal therapies, any frequency shorter than 25 days or longer than 36 days, any length shorter than 3 days or longer than 7 days, and any quantity estimated less or more than previous cycles was defined as abnormal.
We considered days 1–3 of the cycle as menstruation, days 4–9 as the early-mid follicular phase, days 10–14 as the late follicular phase, days 14–21 as the early-mid luteal phase, and days 21–28 as the late luteal phase.
The questionnaire was designed to be self-administered, only one time per respondent, and without any restriction regarding the timing of the first or second dose of the vaccine. The survey was available only in the Italian language, for 30 days, (10 September 2021; 10 October 2021) and distributed by social media (LinkedIn, Facebook, and Twitter).
To limit confounders, in the current analysis, we excluded women with gynaecological and non-gynaecological diseases, undergoing hormonal and non-hormonal treatments, in perimenopause or menopause, as well as who had irregular menstrual cycle in the last 12 months before vaccine administration.
2.2 Study registration and ethical and methodological standards
The study was registered on ClinicalTrial.gov (registration ID: NCT05083065) before starting the enrolment. The design, analysis, interpretation of data, drafting, and revisions conform to the Helsinki Declaration, the Committeeon Publication Ethics (COPE) guidelines (http://publicationethics.org/), and the Checklist for Reporting Results of Internet E-surveys [12], available through the enhancing the quality and transparency of health research (EQUATOR) network (www.equator-network.org). The data collected through the survey were anonymised, taking into account the observational nature of the study, without personal data that could lead to formal identification, so a formal Institutional Review Board (IRB) approval was not mandatory (Code of Federal Regulation, Title 45, part 46, subpart A, sec. 46.101, available through the Office for Human Research Protections, Rockville, USA, and validated by the American Association for Public Opinion Research, Washington, USA). Each patient enrolled in this study gave informed consent to allow data collection and analysis for research purposes before starting the survey. The study was not supported by any fund/grant, and no remuneration was offered to encourage patients to give consent to enter, continue, or complete the survey.
2.3 Statistical analysis
Statistical analyses were mainly descriptive. We reported absolute and relative frequencies for the frequency, length, and quantity of the menstrual cycle after vaccine administration. For selected bivariate associations (frequency by the vaccine type; and frequency, length, and quantity of the menstrual cycle after vaccine administration by the menstrual phase), we reported the p-values from chi-square tests. The cutpoint for the level of significance was set as p < 0.05. For the statistical analyses, we used SAS software, 9.4 release.
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Informed consent: Informed consent has been obtained from all individuals included in this study.
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Ethical approval: Formal IRB approval for this survey was not mandatory (Code of Federal Regulation, Title 45, part 46, subpart A, sec. 46.101, available through the Office for Human Research Protections, Rockville, USA, and validated by the American Association for Public Opinion Research, Washington, USA).
3 Results
From 10 September to 10 October 2021, 369 women answered the online questionnaire. We excluded 205 women due to one or more of the following criteria: women with gynaecological and non-gynaecological diseases, undergoing hormonal and non-hormonal treatments, in perimenopause or menopause, as well as who had irregular menstrual cycle in the last 12 months before the vaccine administration. Among the remaining 164 women, who were in reproductive age and declared regular menstrual cycle before the vaccine administration, mean age was 35.8 ± 7.2 years, mean weight was 62.0 ± 14.3 kg, and mean height was 164.5 ± 6.3 cm (mean BMI: 22.9 ± 5.0).
3.1 Menstrual cycle analysis after the first dose of vaccine
Among the whole population who received at least the first dose (single in the case of Janssen by Johnson & Johnson), 9 women had the first dose of vaccine using Vaxzevria (AstraZeneca), 133 using Comirnaty (Pfizer-BioNTech), 19 using Spikevax (Moderna), and 3 using Janssen (Johnson & Johnson).
The first dose of vaccine was administered during menstruation in 23 women, during the early-mid follicular phase in 26 women, during the late follicular phase in 36 women, during the early-mid luteal phase in 19 women, and during the late luteal phase in 19 women; 41 women declared they did not remember the phase of the menstrual cycle during which the first dose of the vaccine was administered.
The analysis of frequency, length, and quantity of the menstrual cycle after the administration of the first dose of the vaccine is reported in Table 1, stratified for the type of vaccine and the phase of the menstrual cycle during which the vaccine was administered.
Analysis of frequency, length, and quantity of the menstrual cycle after the administration of the first dose of vaccine, stratified for the type of vaccine and the phase of the menstrual cycle during which the vaccine was administered
Type of vaccine | Phase of the menstrual cycle during administration | |||||||||
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Vaxzevria (AstraZeneca) | Comirnaty (Pfizer-BioNtech) | Spikevax (Moderna) | Janssen (Johnson & Johnson) | Menstruation | Early-mid follicular phase | Late follicular phase | Early-mid luteal phase | Late luteal phase | Unknown | |
Frequency | ||||||||||
I did not notice any variation of the frequency | 3 (33.3%) | 58 (42.9%) | 10 (52.6%) | 2 (66.7%) | 11 (43.5%) | 9 (34.6%) | 13 (36.1%) | 4 (21.1%) | 9 (47.4%) | 27 (65.9%) |
I did not have menstrual cycle | 1 (11.1%) | 6 (4.5%) | 1 (5.3%) | 0 | 1 (4.3%) | 1 (3.8%) | 0 | 3 (15.8%) | 1 (5.3%) | 2 (4.9%) |
Menstruation arrived 1–5 days earlier than expected | 3 (33.3%) | 24 (18%) | 4 (21.1%) | 1 (33.3%) | 5 (21.7%) | 7 (26.9%) | 7 (19.4%) | 3 (15.8%) | 4 (21.1%) | 6 (14.6%) |
Menstruation arrived 5–10 days earlier than expected | 1 (11.1%) | 9 (6.8%) | 2 (10.5%) | 0 | 1 (4.3%) | 2 (7.7%) | 3 (8.3%) | 3 (15.8%) | 1 (5.3%) | 2 (4.9%) |
Menstruation arrived more than 10 days earlier than expected | 1 (11.1%) | 11 (8.3%) | 1 (5.3%) | 0 | 2 (8.7%) | 4 (15.4%) | 4 (11.1%) | 1 (5.3%) | 1 (5.3%) | 1 (2.4%) |
Menstruation arrived 1–5 days later than expected | 0 | 12 (9%) | 1 (5.3%) | 0 | 0 | 2 (7.7%) | 4 (11.1%) | 3 (15.8%) | 3 (15.8%) | 1 (2.4%) |
Menstruation arrived 5–10 days later than expected | 0 | 7 (5.3%) | 0 | 0 | 1 (4.3%) | 0 | 4 (11.1%) | 2 (10.5%) | 0 | 0 |
Menstruation arrived more than 10 days later than expected | 0 | 6 (4.3%) | 0 | 0 | 2 (8.7%) | 1 (3.8%) | 1 (2.8%) | 0 | 0 | 2 (4.9%) |
Totals | 9 (100%) | 133 (100%) | 19 (100%) | 3 (100%) | 23 (100%) | 26 (100%) | 36 (100%) | 19 (100%) | 19 (100%) | 41 (100%) |
Length | ||||||||||
I did not notice any variation of the length | 4 (44.4%) | 78 (58.6%) | 9 (47.4%) | 1 (33.3%) | 13 (56.5%) | 15 (57.7%) | 21 (58.3%) | 6 (31.6%) | 11 (57.9%) | 26 (63.4%) |
I had spotting | 2 (22.2%) | 12 (9%) | 0 | 0 | 2 (8.7%) | 2 (7.7%) | 2 (5.6%) | 3 (15.8%) | 1 (5.3%) | 4 (9.8%) |
Menstruation lasted more than 7 days | 2 (22.2%) | 21 (15.8%) | 3 (15.8%) | 2 (66.7%) | 4 (17.4%) | 5 (19.2%) | 6 (16.7%) | 7 (36.8%) | 3 (15.8%) | 3 (7.3%) |
Menstruation lasted less than 3 days | 1 (11.1%) | 22 (16.5%) | 7 (36.8%) | 0 | 4 (17.4%) | 4 (15.4%) | 7 (19.4%) | 3 (15.8%) | 4 (21.1%) | 8 (19.5%) |
Totals | 9 (100%) | 133 (100%) | 19 (100%) | 3 (100%) | 23 (100%) | 26 (100%) | 36 (100%) | 19 (100%) | 19 (100%) | 41 (100%) |
Quantity | ||||||||||
I did not notice any variation of the quantity | 3 (33.3%) | 71 (52.6%) | 9 (47.4%) | 1 (33.3%) | 12 (52.2%) | 12 (46.2%) | 20 (55.6%) | 5 (26.3%) | 10 (52.6%) | 25 (58.5%) |
Menstruation was heavier than usual | 5 (55.6%) | 33 (24.8%) | 3 (15.8%) | 2 (66.7%) | 6 (26.1%) | 11 (42.3%) | 8 (22.2%) | 11 (57.9%) | 3 (15.8%) | 4 (9.8%) |
Menstruation was less heavy than usual | 1 (11.1%) | 29 (21.8%) | 7 (36.8%) | 0 | 5 (21.7%) | 3 (11.5%) | 8 (22.2%) | 3 (15.8%) | 6 (31.6%) | 12 (29.3%) |
Totals | 9 (100%) | 133 (100%) | 19 (100%) | 3 (100%) | 23 (100%) | 26 (100%) | 36 (100%) | 19 (100%) | 19 (100%) | 41 (100%) |
Among the women who had menstrual cycle irregularities after the first dose (n = 94), these occurred only during the first month after the vaccination in 28 (29.8%) cases, only during the second month after the vaccination in 5 (5.3%) cases, lasted for both the first and second month in 19 (20.2%) cases, and finally was reported for more than two months in 42 (44.7%) cases.
3.2 Menstrual cycle analysis after the second dose of vaccine
Among the 135 women who received also the second vaccine dose, 8 women had the second dose of vaccine using Vaxzevria (AstraZeneca), 113 using Comirnaty (Pfizer-BioNTech), 14 using Spikevax (Moderna).
The second dose of vaccine was administered during menstruation in 24 women, during the early-mid follicular phase in 22 women, during the late follicular phase in 19 women, during the early-mid luteal phase in 14 women, and during the late luteal phase in 17 women; 39 women declared they did not remember the phase of the menstrual cycle during which the first dose of the vaccine was administered.
The analysis of frequency, length, and quantity of the menstrual cycle after the administration of the second vaccine dose is reported in Table 2, stratified for the type of vaccine and the phase of the menstrual cycle during which the vaccine was administered.
Analysis of frequency, length, and quantity of the menstrual cycle after the administration of the second dose of the vaccine, stratified for the type of vaccine and the phase of the menstrual cycle during which the vaccine was administered
Type of vaccine | Phase of the menstrual cycle during administration | ||||||||
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Vaxzevria (AstraZeneca) | Comirnaty (Pfizer-BioNtech) | Spikevax (Moderna) | Menstruation | Early-mid follicular phase | Late follicular phase | Early-mid luteal phase | Late luteal phase | Unknown | |
Frequency | |||||||||
I did not notice any variation of the frequency | 2 (25%) | 54 (47.8%) | 3 (21.4%) | 9 (37.5%) | 13 (59.1%) | 6 (31.6%) | 8 (57.1%) | 4 (23.5%) | 19 (48.7%) |
I did not have menstrual cycle | 0 | 6 (5.3%) | 1 (7.1%) | 1 (4.2%) | 0 | 1 (5.3%) | 1 (7.1%) | 2 (11.8%) | 2 (5.1%) |
Menstruation arrived 1–5 days earlier than expected | 3 (37.5%) | 14 (12.4%) | 5 (35.7%) | 4 (16.7%) | 1 (4.5%) | 2 (10.5%) | 3 (21.4%) | 6 (35.3%) | 6 (15.4%) |
Menstruation arrived 5–10 days earlier than expected | 1 (12.5%) | 11 (9.7%) | 2 (14.3%) | 3 (12.5%) | 2 (9.1%) | 4 (21.1%) | 0 | 3 (17.6%) | 2 (5.1%) |
Menstruation arrived more than 10 days earlier than expected | 1 (12.5%) | 8 (7.1%) | 2 (14.3%) | 2 (8.3%) | 3 (13.6%) | 4 (21.1%) | 1 (7.1%) | 0 | 1 (2.6%) |
Menstruation arrived 1–5 days later than expected | 0 | 8 (7.1%) | 1 (7.1%) | 3 (12.5%) | 1 (4.5%) | 0 | 0 | 0 | 5 (12.8%) |
Menstruation arrived 5–10 days later than expected | 1 (12.5%) | 3 (2.7%) | 0 | 1 (4.2%) | 1 (4.5%) | 1 (5.3%) | 0 | 1 (5.9%) | 0 |
Menstruation arrived more than 10 days later than expected | 0 | 9 (8%) | 0 | 1 (4.2%) | 1 (4.5%) | 1 (5.3%) | 1 (7.1%) | 1 (5.9%) | 4 (10.3%) |
Totals | 8 (100%) | 113 (100%) | 14 (100%) | 24 (100%) | 22 (100%) | 19 (100%) | 14 (100%) | 17 (100%) | 39 (100%) |
Length | |||||||||
I did not notice any variation of the length | 4 (50%) | 65 (57.5%) | 8 (57.1%) | 15 (62.5%) | 13 (59.1%) | 6 (31.6%) | 7 (50%) | 11 (64.7%) | 25 (64.1%) |
I had spotting | 0 | 5 (4.4%) | 0 | 0 | 0 | 0 | 0 | 0 | 5 (12.8%) |
Menstruation lasted more than 7 days | 4 (50%) | 24 (21.2%) | 4 (28.6%) | 5 (20.8%) | 6 (27.3%) | 9 (47.4%) | 5 (35.7%) | 4 (23.5%) | 3 (7.7%) |
Menstruation lasted less than 3 days | 0 | 19 (16.8%) | 2 (14.3%) | 4 (16.7%) | 3 (13.6%) | 4 (21.1%) | 2 (14.3%) | 2 (11.8%) | 6 (15.4%) |
Totals | 8 (100%) | 113 (100%) | 14 (100%) | 24 (100%) | 22 (100%) | 19 (100%) | 14 (100%) | 17 (100%) | 39 (100%) |
Quantity | |||||||||
I did not notice any variation of the quantity | 3 (37.5%) | 61 (53.1%) | 6 (35.7%) | 10 (41.7%) | 15 (63.6%) | 9 (42.1%) | 7 (50%) | 6 (35.3%) | 23 (59%) |
Menstruation was heavier than usual | 5 (62.5%) | 32 (28.3%) | 4 (28.6%) | 9 (37.5%) | 4 (18.2%) | 7 (36.8%) | 6 (42.9%) | 7 (41.2%) | 8 (20.5%) |
Menstruation was less heavy than usual | 0 | 20 (17.7%) | 4 (28.6%) | 5 (20.8%) | 3 (13.6%) | 3 (15.8%) | 1 (7.1%) | 4 (23.5%) | 8 (20.5%) |
Totals | 8 (100%) | 113 (100%) | 14 (100%) | 24 (100%) | 22 (100%) | 19 (100%) | 14 (100%) | 17 (100%) | 39 (100%) |
Among the women who had menstrual cycle irregularities after the second dose (n = 84), these occurred only during the first month after the vaccination in 19 (22.6%) cases, only during the second month after the vaccination in 6 (7.1%) cases, lasted for both the first and second month in 21 (25%) cases, and finally was reported for more than two months in 38 (45.2%) cases.
4 Discussion
4.1 Main findings after the first dose of vaccine
After the first dose of vaccine, 66.7% of women who received Vaxzevria (AstraZeneca), 57.1% of women who received Comirnaty (Pfizer-BioNTech), 47.4% of women who received Spikevax (Moderna), and 33.3% of women who received Janssen (Johnson & Johnson) reported alterations in the frequency of the subsequent menstrual cycle. Most of these women had menstruation 1–5 days earlier than expected, and this alteration occurred mainly when the first dose of vaccine was administered during the first 14 days of the menstrual cycle. However, we did not find significant differences (p = 0.45) in the occurrence of this menstrual irregularity based on when the first vaccine dose was administered (follicular versus luteal phase). Moreover, we did not find significant differences (p = 0.60) between recombinant (Vaxzevria and Janssen) and mRNA vaccines (Comirnaty and Moderna).
Additionally, after the first dose, 55.6% of women who received Vaxzevria (AstraZeneca), 41.4% of women who received Comirnaty (Pfizer-BioNTech), 52.6% of women who received Spikevax (Moderna), and 66.7% of women who received Janssen (Johnson & Johnson) reported alteration in the length of the subsequent menstrual cycle. Among these women, the most common alteration was menstruation that lasted more than usual, which occurred mainly when the vaccine was administered during the early luteal phase, although we did not find significant differences (p = 0.90) based on when the first vaccine dose was administered (follicular versus luteal phase).
Finally, after the first dose, 66.7% of women who received Vaxzevria (AstraZeneca), 47.4% of women who received Comirnaty (Pfizer-BioNTech), 52.6% of women who received Spikevax (Moderna), and 66.7% of the women who received Janssen (Johnson & Johnson) declared alteration in the quantity of the subsequent menstrual flow. Among these women, the most common alteration was heavier menstruation than usual, which occurred mainly when the vaccine was administered during the first 14 days of the menstrual cycle. We did not find significant differences (p = 0.77) based on when the first vaccine dose was administered (follicular versus luteal phase). Overall, menstrual cycle irregularities after the first dose of the vaccine spontaneously resolved in approximately half the cases within two months.
4.2 Main findings after the second dose of vaccine
After the second dose of vaccine, 75% of women who received Vaxzevria (AstraZeneca), 52.2% of women who received Comirnaty (Pfizer-BioNTech), and 78.6% of women who received Spikevax (Moderna) reported alteration in the frequency of the subsequent menstrual cycle(s). Similar to the first dose, the most common frequency alteration was menstruation that arrived 1–5 days earlier than expected. We did not find significant differences (p = 0.51) between recombinant (Vaxzevria and Janssen) and mRNA vaccines (Comirnaty and Moderna) or based on when the second vaccine dose was administered (follicular versus luteal phase; p = 0.11).
In addition, 50% of women who received Vaxzevria (AstraZeneca), 42.5% of the women who received Comirnaty (Pfizer-BioNTech), and 42.9% of the women who received Spikevax (Moderna) declared alteration in the length of the subsequent menstrual cycle after the second dose. Consistently with the first dose, the most common occurrence was menstruation that lasted more than usual. We did not find significant differences (p = 0.67) based on when the second vaccine dose was administered (follicular versus luteal phase).
Finally, 62.5% of women who received Vaxzevria (AstraZeneca), 46.9% of women who received Comirnaty (Pfizer-BioNTech), and 64.3% of women who received Spikevax (Moderna) declared alteration in the quantity in the subsequent menstrual flow after the second dose, and the most common occurrence was menstruation heavier than usual. We did not find significant differences (p = 0.69) based on when the second vaccine dose was administered (follicular versus luteal phase). Similar to the first dose, menstrual cycle irregularities after the second dose of vaccine spontaneously resolved in approximately half of the cases within two months.
4.3 Strengths and limitations
To the best of our knowledge, this is one of the few preliminary reports aimed to investigate menstrual cycle irregularities among women who received the first and second doses of the COVID-19 vaccine. To avoid potential biases, we excluded from the current analysis women with gynaecological and non-gynaecological diseases, undergoing hormonal and non-hormonal treatments, in perimenopause or menopause, as well as who had irregular menstrual cycle in the last 12 months before the vaccine administration. In addition, we investigated the alteration of frequency, length, and quantity of the subsequent menstrual cycles, stratifying data for the type of vaccine and the phase of the menstrual cycle during which the first and second doses were administered.
Nevertheless, several limitations should be taken into account for a proper and cautious data interpretation: first of all, we used a customised questionnaire, without a previous validation; second, this questionnaire was self-administered and diffused among the general population through social media, so we cannot rule out that women who had menstrual cycle irregularities after COVID-19 vaccination were more motivated to answer than women who did not experience this event; for the same reason, we could not exactly measure the quantity of the menstrual cycle, and we left this parameter as a subjective evaluation from the patient’s perspective (more or less heavy than usual), whereas we used exact ranges for the frequency and length of the menstrual cycle. Overall, the recall bias may be significant for this preliminary report. From the methodological point of view, we do not have a control group, so our report is aimed only to offer a description of what we observed, without any possibility to infer cause–effect. Finally, the number of women who answered the questionnaire is limited, impeding the observation of statistically significant associations between menstrual irregularities and the vaccine type or the menstrual phase at the time of administration.
4.4 Interpretation and comparison with other literature studies
Overall, our preliminary report highlights that approximately 50–60% of reproductive age women who received the first dose of COVID-19 vaccine had menstrual cycle irregularities, regardless of the type of vaccine administered. The occurrence of menstrual irregularities seems to be slightly higher (60–70%) after the second dose, suggesting a potential additive effect. After both the first and second doses of vaccine, the most common alterations seem to be anticipated, longer, and heavier menstrual cycle than expected and usual.
Currently, more than 30,000 reports of irregularities in the menstrual cycle have been reported by 2 September 2021, across all COVID-19 vaccines [13]. A longitudinal study to explore the potential impacts of COVID-19 vaccination on menstruation is currently ongoing, supported by the NIH’s Eunice Kennedy Shriver National Institute of Child Health and Human Development and the NIH Office of Research on Women’s Health [9]. Although the regulatory agencies did not find convincing evidence of a link between changes to menstrual periods and COVID-19 vaccines, concern regarding this specific issue has been raised by an editorial recently published in the British Journal of Medicine [8]. According to recent data comparing women who received vaccination and unvaccinated controls [14], COVID-19 vaccine was associated with a less than 1 day change in the cycle length for both vaccine-dose cycles compared with pre-vaccine cycles (first dose 0.71 day-increase, 98.75% confidence interval (CI) 0.47–0.94; second dose 0.91, 98.75% CI 0.63–1.19). Other reports, still in the pre-print phase, have provided further support to the hypothesis. Menstrual abnormalities have been recorded in 20–42% of vaccinated women, while 66% of post-menopausal women reported breakthrough bleeding [15,16]. Our results are in line with these last reports.
Menstrual changes following vaccination are indeed not so unusual, given that such modifications were observed after vaccination for other microbes, like the human papilloma virus [17], or human hormones, such as human chorionic gonadotropin [18]. Such disturbances could likely be ascribed to the inflammatory/immunological reaction ensuing from adjuvants comprised in the vaccines, at least in some cases [19]. However, we cannot discard that the COVID-19-related spike protein could exert a causative pathogenic role, as similar changes in menstrual cycles have been recorded during COVID-19 infection [20]. Moreover, diffusion of the spike protein in women tissues – either linked to COVID-19 infection or released after mRNA-based vaccination – can also interfere with the endocrine homeostasis of the menstrual cycle, given that the use of combined oral contraceptives was associated with lower odds of reporting any menstrual changes [15]. These findings provide further confirmation of the protective effect of oestrogens in mitigating the severity of COVID-19-related clinical outcomes, as previously reported [21].
Although speculative, we may hypothesise that what we observed could be due, at least in part, to phase-specific hormonal variation caused by potential pro-inflammatory and pro-coagulative changes. Indeed, several pieces of evidence suggest crosstalk between inflammatory homeostasis and menstrual cycle regulation [10], which may be slightly disturbed by temporary hormonal variation and secondary to the inflammatory reaction induced by the vaccine. Remarkably, reproductive toxicity studies performed in the mouse models with Comirnaty (Pfizer-BioNTech) [22], Spikevax (Moderna) [23], Vaxzevria (AstraZeneca) [24], and Janssen (Johnson & Johnson) [25] reveal no special hazard for humans regarding fertility. Although reported changes to the menstrual cycle after vaccination are temporary and self-limiting and no cases resulted in clinically significant consequences, the link between COVID-19 vaccination and irregularities in the menstrual cycle deserves to be investigated in further specific studies. We hope that the results of our study will help for a proper counselling and mitigate fear about potential side effects of COVID-19 vaccination, even considering the potential detrimental role of COVID-19 pandemic itself on the quality of life and mental health [26,27].
5 Conclusion
According to our preliminary report, more than half of reproductive-age women who received the first and second doses of COVID-19 vaccine had menstrual cycle irregularities at least in the following menstrual cycle, regardless of the vaccine type and the phase of the menstrual cycle during which the vaccine was administered. However, the occurrence of menstrual irregularities after both the first and second doses of the vaccine was found to self-resolve in approximately half the cases within two months, without clinically relevant consequences.
Although we solicit further studies to confirm or disregard this observational evidence on large dataset analysis, we suggest considering this element during the counselling of women who received the COVID-19 vaccine, letting them know about the potential occurrence of a temporary and self-limiting menstrual cycle irregularity in the subsequent month(s). In addition, we take the opportunity to highlight clearly that our preliminary report does not allow us to draw any firm conclusion about a potential cause–effect correlation between the COVID-19 vaccine and menstrual irregularities, or about any potential fertility impairment.
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Funding information: Authors state no funding involved.
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Authors contributions: ASL and MC designed and planned the study. ASL, AC, and FG were responsible for data acquisition. GV and MMF had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. ASL was responsible for the initial draft of the manuscript. SG, MB, and MC edited the manuscript. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.
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Conflict of interest: All authors declare no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work. Dr Antonio Simone Laganà and Dr Simone Garzon are Editors in Open Medicine, but this did not affect the peer review process.
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Data availability statement: The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.
References
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© 2022 Antonio Simone Laganà et al., published by De Gruyter
This work is licensed under the Creative Commons Attribution 4.0 International License.
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Articles in the same Issue
- Research Articles
- AMBRA1 attenuates the proliferation of uveal melanoma cells
- A ceRNA network mediated by LINC00475 in papillary thyroid carcinoma
- Differences in complications between hepatitis B-related cirrhosis and alcohol-related cirrhosis
- Effect of gestational diabetes mellitus on lipid profile: A systematic review and meta-analysis
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- Effects of miRNA-199a-5p on cell proliferation and apoptosis of uterine leiomyoma by targeting MED12
- Does diabetes affect paraneoplastic thrombocytosis in colorectal cancer?
- Is there any effect on imprinted genes H19, PEG3, and SNRPN during AOA?
- Leptin and PCSK9 concentrations are associated with vascular endothelial cytokines in patients with stable coronary heart disease
- Pericentric inversion of chromosome 6 and male fertility problems
- Staple line reinforcement with nebulized cyanoacrylate glue in laparoscopic sleeve gastrectomy: A propensity score-matched study
- Retrospective analysis of crescent score in clinical prognosis of IgA nephropathy
- Expression of DNM3 is associated with good outcome in colorectal cancer
- Activation of SphK2 contributes to adipocyte-induced EOC cell proliferation
- CRRT influences PICCO measurements in febrile critically ill patients
- SLCO4A1-AS1 mediates pancreatic cancer development via miR-4673/KIF21B axis
- lncRNA ACTA2-AS1 inhibits malignant phenotypes of gastric cancer cells
- circ_AKT3 knockdown suppresses cisplatin resistance in gastric cancer
- Prognostic value of nicotinamide N-methyltransferase in human cancers: Evidence from a meta-analysis and database validation
- GPC2 deficiency inhibits cell growth and metastasis in colon adenocarcinoma
- A pan-cancer analysis of the oncogenic role of Holliday junction recognition protein in human tumors
- Radiation increases COL1A1, COL3A1, and COL1A2 expression in breast cancer
- Association between preventable risk factors and metabolic syndrome
- miR-29c-5p knockdown reduces inflammation and blood–brain barrier disruption by upregulating LRP6
- Cardiac contractility modulation ameliorates myocardial metabolic remodeling in a rabbit model of chronic heart failure through activation of AMPK and PPAR-α pathway
- Quercitrin protects human bronchial epithelial cells from oxidative damage
- Smurf2 suppresses the metastasis of hepatocellular carcinoma via ubiquitin degradation of Smad2
- circRNA_0001679/miR-338-3p/DUSP16 axis aggravates acute lung injury
- Sonoclot’s usefulness in prediction of cardiopulmonary arrest prognosis: A proof of concept study
- Four drug metabolism-related subgroups of pancreatic adenocarcinoma in prognosis, immune infiltration, and gene mutation
- Decreased expression of miR-195 mediated by hypermethylation promotes osteosarcoma
- LMO3 promotes proliferation and metastasis of papillary thyroid carcinoma cells by regulating LIMK1-mediated cofilin and the β-catenin pathway
- Cx43 upregulation in HUVECs under stretch via TGF-β1 and cytoskeletal network
- Evaluation of menstrual irregularities after COVID-19 vaccination: Results of the MECOVAC survey
- Histopathologic findings on removed stomach after sleeve gastrectomy. Do they influence the outcome?
- Analysis of the expression and prognostic value of MT1-MMP, β1-integrin and YAP1 in glioma
- Optimal diagnosis of the skin cancer using a hybrid deep neural network and grasshopper optimization algorithm
- miR-223-3p alleviates TGF-β-induced epithelial-mesenchymal transition and extracellular matrix deposition by targeting SP3 in endometrial epithelial cells
- Clinical value of SIRT1 as a prognostic biomarker in esophageal squamous cell carcinoma, a systematic meta-analysis
- circ_0020123 promotes cell proliferation and migration in lung adenocarcinoma via PDZD8
- miR-22-5p regulates the self-renewal of spermatogonial stem cells by targeting EZH2
- hsa-miR-340-5p inhibits epithelial–mesenchymal transition in endometriosis by targeting MAP3K2 and inactivating MAPK/ERK signaling
- circ_0085296 inhibits the biological functions of trophoblast cells to promote the progression of preeclampsia via the miR-942-5p/THBS2 network
- TCD hemodynamics findings in the subacute phase of anterior circulation stroke patients treated with mechanical thrombectomy
- Development of a risk-stratification scoring system for predicting risk of breast cancer based on non-alcoholic fatty liver disease, non-alcoholic fatty pancreas disease, and uric acid
- Tollip promotes hepatocellular carcinoma progression via PI3K/AKT pathway
- circ_0062491 alleviates periodontitis via the miR-142-5p/IGF1 axis
- Human amniotic fluid as a source of stem cells
- lncRNA NONRATT013819.2 promotes transforming growth factor-β1-induced myofibroblastic transition of hepatic stellate cells by miR24-3p/lox
- NORAD modulates miR-30c-5p-LDHA to protect lung endothelial cells damage
- Idiopathic pulmonary fibrosis telemedicine management during COVID-19 outbreak
- Risk factors for adverse drug reactions associated with clopidogrel therapy
- Serum zinc associated with immunity and inflammatory markers in Covid-19
- The relationship between night shift work and breast cancer incidence: A systematic review and meta-analysis of observational studies
- LncRNA expression in idiopathic achalasia: New insight and preliminary exploration into pathogenesis
- Notoginsenoside R1 alleviates spinal cord injury through the miR-301a/KLF7 axis to activate Wnt/β-catenin pathway
- Moscatilin suppresses the inflammation from macrophages and T cells
- Zoledronate promotes ECM degradation and apoptosis via Wnt/β-catenin
- Epithelial-mesenchymal transition-related genes in coronary artery disease
- The effect evaluation of traditional vaginal surgery and transvaginal mesh surgery for severe pelvic organ prolapse: 5 years follow-up
- Repeated partial splenic artery embolization for hypersplenism improves platelet count
- Low expression of miR-27b in serum exosomes of non-small cell lung cancer facilitates its progression by affecting EGFR
- Exosomal hsa_circ_0000519 modulates the NSCLC cell growth and metastasis via miR-1258/RHOV axis
- miR-455-5p enhances 5-fluorouracil sensitivity in colorectal cancer cells by targeting PIK3R1 and DEPDC1
- The effect of tranexamic acid on the reduction of intraoperative and postoperative blood loss and thromboembolic risk in patients with hip fracture
- Isocitrate dehydrogenase 1 mutation in cholangiocarcinoma impairs tumor progression by sensitizing cells to ferroptosis
- Artemisinin protects against cerebral ischemia and reperfusion injury via inhibiting the NF-κB pathway
- A 16-gene signature associated with homologous recombination deficiency for prognosis prediction in patients with triple-negative breast cancer
- Lidocaine ameliorates chronic constriction injury-induced neuropathic pain through regulating M1/M2 microglia polarization
- MicroRNA 322-5p reduced neuronal inflammation via the TLR4/TRAF6/NF-κB axis in a rat epilepsy model
- miR-1273h-5p suppresses CXCL12 expression and inhibits gastric cancer cell invasion and metastasis
- Clinical characteristics of pneumonia patients of long course of illness infected with SARS-CoV-2
- circRNF20 aggravates the malignancy of retinoblastoma depending on the regulation of miR-132-3p/PAX6 axis
- Linezolid for resistant Gram-positive bacterial infections in children under 12 years: A meta-analysis
- Rack1 regulates pro-inflammatory cytokines by NF-κB in diabetic nephropathy
- Comprehensive analysis of molecular mechanism and a novel prognostic signature based on small nuclear RNA biomarkers in gastric cancer patients
- Smog and risk of maternal and fetal birth outcomes: A retrospective study in Baoding, China
- Let-7i-3p inhibits the cell cycle, proliferation, invasion, and migration of colorectal cancer cells via downregulating CCND1
- β2-Adrenergic receptor expression in subchondral bone of patients with varus knee osteoarthritis
- Possible impact of COVID-19 pandemic and lockdown on suicide behavior among patients in Southeast Serbia
- In vitro antimicrobial activity of ozonated oil in liposome eyedrop against multidrug-resistant bacteria
- Potential biomarkers for inflammatory response in acute lung injury
- A low serum uric acid concentration predicts a poor prognosis in adult patients with candidemia
- Antitumor activity of recombinant oncolytic vaccinia virus with human IL2
- ALKBH5 inhibits TNF-α-induced apoptosis of HUVECs through Bcl-2 pathway
- Risk prediction of cardiovascular disease using machine learning classifiers
- Value of ultrasonography parameters in diagnosing polycystic ovary syndrome
- Bioinformatics analysis reveals three key genes and four survival genes associated with youth-onset NSCLC
- Identification of autophagy-related biomarkers in patients with pulmonary arterial hypertension based on bioinformatics analysis
- Protective effects of glaucocalyxin A on the airway of asthmatic mice
- Overexpression of miR-100-5p inhibits papillary thyroid cancer progression via targeting FZD8
- Bioinformatics-based analysis of SUMOylation-related genes in hepatocellular carcinoma reveals a role of upregulated SAE1 in promoting cell proliferation
- Effectiveness and clinical benefits of new anti-diabetic drugs: A real life experience
- Identification of osteoporosis based on gene biomarkers using support vector machine
- Tanshinone IIA reverses oxaliplatin resistance in colorectal cancer through microRNA-30b-5p/AVEN axis
- miR-212-5p inhibits nasopharyngeal carcinoma progression by targeting METTL3
- Association of ST-T changes with all-cause mortality among patients with peripheral T-cell lymphomas
- LINC00665/miRNAs axis-mediated collagen type XI alpha 1 correlates with immune infiltration and malignant phenotypes in lung adenocarcinoma
- The perinatal factors that influence the excretion of fecal calprotectin in premature-born children
- Effect of femoral head necrosis cystic area on femoral head collapse and stress distribution in femoral head: A clinical and finite element study
- Does the use of 3D-printed cones give a chance to postpone the use of megaprostheses in patients with large bone defects in the knee joint?
- lncRNA HAGLR modulates myocardial ischemia–reperfusion injury in mice through regulating miR-133a-3p/MAPK1 axis
- Protective effect of ghrelin on intestinal I/R injury in rats
- In vivo knee kinematics of an innovative prosthesis design
- Relationship between the height of fibular head and the incidence and severity of knee osteoarthritis
- lncRNA WT1-AS attenuates hypoxia/ischemia-induced neuronal injury during cerebral ischemic stroke via miR-186-5p/XIAP axis
- Correlation of cardiac troponin T and APACHE III score with all-cause in-hospital mortality in critically ill patients with acute pulmonary embolism
- LncRNA LINC01857 reduces metastasis and angiogenesis in breast cancer cells via regulating miR-2052/CENPQ axis
- Endothelial cell-specific molecule 1 (ESM1) promoted by transcription factor SPI1 acts as an oncogene to modulate the malignant phenotype of endometrial cancer
- SELENBP1 inhibits progression of colorectal cancer by suppressing epithelial–mesenchymal transition
- Visfatin is negatively associated with coronary artery lesions in subjects with impaired fasting glucose
- Treatment and outcomes of mechanical complications of acute myocardial infarction during the Covid-19 era: A comparison with the pre-Covid-19 period. A systematic review and meta-analysis
- Neonatal stroke surveillance study protocol in the United Kingdom and Republic of Ireland
- Oncogenic role of TWF2 in human tumors: A pan-cancer analysis
- Mean corpuscular hemoglobin predicts the length of hospital stay independent of severity classification in patients with acute pancreatitis
- Association of gallstone and polymorphisms of UGT1A1*27 and UGT1A1*28 in patients with hepatitis B virus-related liver failure
- TGF-β1 upregulates Sar1a expression and induces procollagen-I secretion in hypertrophic scarring fibroblasts
- Antisense lncRNA PCNA-AS1 promotes esophageal squamous cell carcinoma progression through the miR-2467-3p/PCNA axis
- NK-cell dysfunction of acute myeloid leukemia in relation to the renin–angiotensin system and neurotransmitter genes
- The effect of dilution with glucose and prolonged injection time on dexamethasone-induced perineal irritation – A randomized controlled trial
- miR-146-5p restrains calcification of vascular smooth muscle cells by suppressing TRAF6
- Role of lncRNA MIAT/miR-361-3p/CCAR2 in prostate cancer cells
- lncRNA NORAD promotes lung cancer progression by competitively binding to miR-28-3p with E2F2
- Noninvasive diagnosis of AIH/PBC overlap syndrome based on prediction models
- lncRNA FAM230B is highly expressed in colorectal cancer and suppresses the maturation of miR-1182 to increase cell proliferation
- circ-LIMK1 regulates cisplatin resistance in lung adenocarcinoma by targeting miR-512-5p/HMGA1 axis
- LncRNA SNHG3 promoted cell proliferation, migration, and metastasis of esophageal squamous cell carcinoma via regulating miR-151a-3p/PFN2 axis
- Risk perception and affective state on work exhaustion in obstetrics during the COVID-19 pandemic
- lncRNA-AC130710/miR-129-5p/mGluR1 axis promote migration and invasion by activating PKCα-MAPK signal pathway in melanoma
- SNRPB promotes cell cycle progression in thyroid carcinoma via inhibiting p53
- Xylooligosaccharides and aerobic training regulate metabolism and behavior in rats with streptozotocin-induced type 1 diabetes
- Serpin family A member 1 is an oncogene in glioma and its translation is enhanced by NAD(P)H quinone dehydrogenase 1 through RNA-binding activity
- Silencing of CPSF7 inhibits the proliferation, migration, and invasion of lung adenocarcinoma cells by blocking the AKT/mTOR signaling pathway
- Ultrasound-guided lumbar plexus block versus transversus abdominis plane block for analgesia in children with hip dislocation: A double-blind, randomized trial
- Relationship of plasma MBP and 8-oxo-dG with brain damage in preterm
- Identification of a novel necroptosis-associated miRNA signature for predicting the prognosis in head and neck squamous cell carcinoma
- Delayed femoral vein ligation reduces operative time and blood loss during hip disarticulation in patients with extremity tumors
- The expression of ASAP3 and NOTCH3 and the clinicopathological characteristics of adult glioma patients
- Longitudinal analysis of factors related to Helicobacter pylori infection in Chinese adults
- HOXA10 enhances cell proliferation and suppresses apoptosis in esophageal cancer via activating p38/ERK signaling pathway
- Meta-analysis of early-life antibiotic use and allergic rhinitis
- Marital status and its correlation with age, race, and gender in prognosis of tonsil squamous cell carcinomas
- HPV16 E6E7 up-regulates KIF2A expression by activating JNK/c-Jun signal, is beneficial to migration and invasion of cervical cancer cells
- Amino acid profiles in the tissue and serum of patients with liver cancer
- Pain in critically ill COVID-19 patients: An Italian retrospective study
- Immunohistochemical distribution of Bcl-2 and p53 apoptotic markers in acetamiprid-induced nephrotoxicity
- Estradiol pretreatment in GnRH antagonist protocol for IVF/ICSI treatment
- Long non-coding RNAs LINC00689 inhibits the apoptosis of human nucleus pulposus cells via miR-3127-5p/ATG7 axis-mediated autophagy
- The relationship between oxygen therapy, drug therapy, and COVID-19 mortality
- Monitoring hypertensive disorders in pregnancy to prevent preeclampsia in pregnant women of advanced maternal age: Trial mimicking with retrospective data
- SETD1A promotes the proliferation and glycolysis of nasopharyngeal carcinoma cells by activating the PI3K/Akt pathway
- The role of Shunaoxin pills in the treatment of chronic cerebral hypoperfusion and its main pharmacodynamic components
- TET3 governs malignant behaviors and unfavorable prognosis of esophageal squamous cell carcinoma by activating the PI3K/AKT/GSK3β/β-catenin pathway
- Associations between morphokinetic parameters of temporary-arrest embryos and the clinical prognosis in FET cycles
- Long noncoding RNA WT1-AS regulates trophoblast proliferation, migration, and invasion via the microRNA-186-5p/CADM2 axis
- The incidence of bronchiectasis in chronic obstructive pulmonary disease
- Integrated bioinformatics analysis shows integrin alpha 3 is a prognostic biomarker for pancreatic cancer
- Inhibition of miR-21 improves pulmonary vascular responses in bronchopulmonary dysplasia by targeting the DDAH1/ADMA/NO pathway
- Comparison of hospitalized patients with severe pneumonia caused by COVID-19 and influenza A (H7N9 and H1N1): A retrospective study from a designated hospital
- lncRNA ZFAS1 promotes intervertebral disc degeneration by upregulating AAK1
- Pathological characteristics of liver injury induced by N,N-dimethylformamide: From humans to animal models
- lncRNA ELFN1-AS1 enhances the progression of colon cancer by targeting miR-4270 to upregulate AURKB
- DARS-AS1 modulates cell proliferation and migration of gastric cancer cells by regulating miR-330-3p/NAT10 axis
- Dezocine inhibits cell proliferation, migration, and invasion by targeting CRABP2 in ovarian cancer
- MGST1 alleviates the oxidative stress of trophoblast cells induced by hypoxia/reoxygenation and promotes cell proliferation, migration, and invasion by activating the PI3K/AKT/mTOR pathway
- Bifidobacterium lactis Probio-M8 ameliorated the symptoms of type 2 diabetes mellitus mice by changing ileum FXR-CYP7A1
- circRNA DENND1B inhibits tumorigenicity of clear cell renal cell carcinoma via miR-122-5p/TIMP2 axis
- EphA3 targeted by miR-3666 contributes to melanoma malignancy via activating ERK1/2 and p38 MAPK pathways
- Pacemakers and methylprednisolone pulse therapy in immune-related myocarditis concomitant with complete heart block
- miRNA-130a-3p targets sphingosine-1-phosphate receptor 1 to activate the microglial and astrocytes and to promote neural injury under the high glucose condition
- Review Articles
- Current management of cancer pain in Italy: Expert opinion paper
- Hearing loss and brain disorders: A review of multiple pathologies
- The rationale for using low-molecular weight heparin in the therapy of symptomatic COVID-19 patients
- Amyotrophic lateral sclerosis and delayed onset muscle soreness in light of the impaired blink and stretch reflexes – watch out for Piezo2
- Interleukin-35 in autoimmune dermatoses: Current concepts
- Recent discoveries in microbiota dysbiosis, cholangiocytic factors, and models for studying the pathogenesis of primary sclerosing cholangitis
- Advantages of ketamine in pediatric anesthesia
- Congenital adrenal hyperplasia. Role of dentist in early diagnosis
- Migraine management: Non-pharmacological points for patients and health care professionals
- Atherogenic index of plasma and coronary artery disease: A systematic review
- Physiological and modulatory role of thioredoxins in the cellular function
- Case Reports
- Intrauterine Bakri balloon tamponade plus cervical cerclage for the prevention and treatment of postpartum haemorrhage in late pregnancy complicated with acute aortic dissection: Case series
- A case of successful pembrolizumab monotherapy in a patient with advanced lung adenocarcinoma: Use of multiple biomarkers in combination for clinical practice
- Unusual neurological manifestations of bilateral medial medullary infarction: A case report
- Atypical symptoms of malignant hyperthermia: A rare causative mutation in the RYR1 gene
- A case report of dermatomyositis with the missed diagnosis of non-small cell lung cancer and concurrence of pulmonary tuberculosis
- A rare case of endometrial polyp complicated with uterine inversion: A case report and clinical management
- Spontaneous rupturing of splenic artery aneurysm: Another reason for fatal syncope and shock (Case report and literature review)
- Fungal infection mimicking COVID-19 infection – A case report
- Concurrent aspergillosis and cystic pulmonary metastases in a patient with tongue squamous cell carcinoma
- Paraganglioma-induced inverted takotsubo-like cardiomyopathy leading to cardiogenic shock successfully treated with extracorporeal membrane oxygenation
- Lineage switch from lymphoma to myeloid neoplasms: First case series from a single institution
- Trismus during tracheal extubation as a complication of general anaesthesia – A case report
- Simultaneous treatment of a pubovesical fistula and lymph node metastasis secondary to multimodal treatment for prostate cancer: Case report and review of the literature
- Two case reports of skin vasculitis following the COVID-19 immunization
- Ureteroiliac fistula after oncological surgery: Case report and review of the literature
- Synchronous triple primary malignant tumours in the bladder, prostate, and lung harbouring TP53 and MEK1 mutations accompanied with severe cardiovascular diseases: A case report
- Huge mucinous cystic neoplasms with adhesion to the left colon: A case report and literature review
- Commentary
- Commentary on “Clinicopathological features of programmed cell death-ligand 1 expression in patients with oral squamous cell carcinoma”
- Rapid Communication
- COVID-19 fear, post-traumatic stress, growth, and the role of resilience
- Erratum
- Erratum to “Tollip promotes hepatocellular carcinoma progression via PI3K/AKT pathway”
- Erratum to “Effect of femoral head necrosis cystic area on femoral head collapse and stress distribution in femoral head: A clinical and finite element study”
- Erratum to “lncRNA NORAD promotes lung cancer progression by competitively binding to miR-28-3p with E2F2”
- Retraction
- Expression and role of ABIN1 in sepsis: In vitro and in vivo studies
- Retraction to “miR-519d downregulates LEP expression to inhibit preeclampsia development”
- Special Issue Computational Intelligence Methodologies Meets Recurrent Cancers - Part II
- Usefulness of close surveillance for rectal cancer patients after neoadjuvant chemoradiotherapy