Menopause and long COVID: What's the connection?

photo of a mature woman sitting at a table with her hands on her temples as if she has a headache

Before the pandemic, Beth was just beginning to experience erratic periods, mood swings, fatigue, and other signs of perimenopause. But after she caught the SARS-CoV-2 virus — and especially after the infection morphed into long COVID — Beth's woes worsened. Short-term memory lapses, along with severe hot flashes and brain fog, joined her prior problems, creating a confusing slurry of symptoms.

"She attributed many of these new symptoms to long COVID, but they're also symptoms we may see as perimenopause progresses," says Dr. Tara Iyer, director of the Menopause and Midlife Clinic at Harvard-affiliated Brigham and Women's Hospital. "I couldn't tell her if one condition was making the other worse."

Four years after COVID's emergence, this predicament is becoming increasingly prevalent — especially since two-thirds of the Americans who have long COVID are women, according to a 2022 analysis in JAMA Network Open.

"There's certainly an exacerbation of symptoms that goes both ways," says Dr. Kathryn Corelli, an internist and menopause specialist at Brigham and Women's Hospital. "Patients with long COVID look like they have worse menopause symptoms. Similarly, it looks like long COVID symptoms are worse when you're going through menopause. It's really hard to tease out."

Estrogen underpinnings

Preliminary research indeed suggests a two-way association between the conditions. Women in midlife who get long COVID — which involves physical and cognitive problems that persist well beyond the initial infection — also seem to develop specific and severe symptoms. These include brain fog, fatigue, new-onset dizziness, and difficulty sleeping through the night, according to a 2021 study in the journal Maturitas.

About half of the 500 women involved in a 2022 study published in PLOS One experienced changes in their menstrual cycles after COVID, including heavier periods and irregular cycles. "This happens in perimenopause too, so assessing what's causing what is not easy," Dr. Corelli says.

Scientists are just beginning to determine both why women suffer disproportionately from long COVID and why the condition appears to influence menstruation and menopause. The disparity between the sexes suggests women's hormones and innate immune differences predispose us to these issues. "We can be pretty confident that estrogen is playing some role," Dr. Iyer says.

Widespread inflammation triggered by long COVID may also affect already-flagging estrogen levels and estrogen receptors throughout the body, Harvard experts say. "We think long COVID involves inflammation, which causes many other symptoms as well," explains Dr. Deborah Gomez Kwolek, a menopause specialist at Brigham and Women's Hospital and internal medicine doctor at Harvard-affiliated Massachusetts General Hospital.

Hormone therapy's role

A 2022 paper bolsters the theory that estrogen is integral in long COVID. It suggests many women have trouble recovering from the illness without estrogen-based hormone therapy.

The notion aligns with what Dr. Corelli witnesses in her practice. "These women who have long COVID and what looks like menopause symptoms have some of the most severe symptoms we see," she says. "But menopause is one area in which we have a therapy [that may help with some symptoms], and you don't know if it will work until you try it."

In this way, hormone therapy is becoming both a treatment and a diagnostic tool. Dr. Iyer prescribed hormone therapy for Beth, for example, which significantly improved her symptoms. "We didn't get to perfect — she definitely had long COVID," Dr. Iyer says. "It's just difficult to say if perimenopause was making those symptoms much worse, or if the primary issue was perimenopause."

But there are caveats to using hormone therapy. Not every woman can take it — or wants to. Even if she does, "fixing the hormone fluctuations that occur in menopause — the brain fog, lack of concentration, hot flashes, mood swings, irritability, all of those things — doesn't fix the underlying long COVID, in my experience," Dr. Corelli says.

"Women come in very hopeful that we're going to be able to start hormones or nonhormonal therapies to improve all their symptoms, and it doesn't always work," she says. "But that's true for women in just menopause, too."

Prone to misdiagnosis

Because of the symptom overlap between menopause and long COVID, women in midlife may have trouble being correctly diagnosed with one or the other, a 2021 paper in The Lancet Regional Health–Europe cautions. Harvard experts strenuously agree.

"We have this whole complex of different things going on," Dr. Iyer says, "and there's no test that can say that a certain percentage of a significant increase in anxiety and brain fog, for instance, is from hormone changes and a certain percentage is from long COVID."

Diagnosing either condition on its own is still a dicey prospect as well. "We're at ground zero, almost, in getting doctors to recognize perimenopause," Dr. Kwolek says. "And if doctors don't recognize either one — and especially the perimenopause part we do have treatment for — women are going to suffer. Often, these symptoms also affect their relationships and jobs, so they're suffering beyond the physical symptoms."

Even our sex lives aren't immune from COVID

As if the pandemic hasn't caused enough misery, a recent study suggests that COVID and long COVID can affect women's sex lives, impairing desire, arousal, orgasm, and other factors.

The study, which was published in the February 2024 issue of The Journal of Sexual Medicine, is believed to be the first analysis highlighting long COVID's effects on women's sexual health. Researchers surveyed more than 2,300 women online, half of whom said they hadn't had COVID and the remainder reporting they'd tested positive for the infection at one time. One-quarter of those who'd had COVID reported also having extended symptoms indicative of long COVID. Only women who said they'd had sex in the previous month were included in the results.

Participants who'd had COVID reported lower levels of desire, arousal, lubrication, and sexual satisfaction than women who hadn't. Orgasm and pain scores between the two groups didn't differ significantly. But within the COVID group, women who'd experienced long-lasting COVID symptoms had markedly worse scores in arousal, lubrication, orgasm, and pain.

"It's no surprise," says Dr. Tara Iyer, director of the Menopause and Midlife Clinic at Brigham and Women's Hospital. "Having COVID symptoms puts a lot of stress on the body. Many of the symptoms associated with long COVID — like aches, brain fog, and fatigue — can affect libido as well."

The findings also suggested that COVID can interfere with cognitive aspects of sexual function — essentially, "the mental aspects that tie into having a positive sexual experience," Dr. Iyer says.

If you've had sexual difficulties following a COVID infection, it's crucial to push past any awkwardness and tell your gynecologist. She may suggest treatments or workarounds for symptoms.

"It's very helpful if you can see a specialist who addresses female sexual dysfunction," Dr. Iyer says. "Even if we can't say we know the exact causes of what you're experiencing, there still may be treatment available."

Care improvement tactics

Women who find themselves in the crosshairs of both perimenopause and long COVID do have options to improve their care. Harvard experts suggest these strategies:

Seek a specialized long COVID clinic. Such a program can ensure you consult with someone knowledgeable about the condition, Dr. Kwolek says. "If it's part of a clinical trial, think also about getting into that," she adds.

Consider hormone therapy. "There's no blood test or other specific test that we can do to identify the driving force of your symptoms," Dr. Iyer says. "You may need hormone therapy to help diagnose you." Other non-hormonal medications may also help with menopausal symptoms.

See a menopause specialist. Keep in mind that this specialist might not be your primary care doctor or regular OB/GYN. "Not every provider is well versed in midlife women's health, and they may not have the answer," Dr. Iyer says. "It's important to seek out someone who's comfortable in that space."

Be persistent. Obtaining effective treatment "is sometimes a longer road," Dr. Kwolek says. "Don't get discouraged."

Follow up. Since research about long COVID and menopause is quickly evolving, checking back with your doctor in just three or six months could yield more comprehensive advice. "It's extremely important to follow up with providers working in these specialties to reassess if there are improvements in treatment," Dr. Iyer says.