Psychological Investigation in Patients With Polycystic Ovary Syndrome

Fatemeh Bazarganipour; Saeide Ziaei; Ali Montazeri; Fatemeh Foroozanfard; Anoshirvan Kazemnejad; Soghrat Faghihzadeh


Health and Quality of Life Outcomes. 2013;11(141) 

In This Article


The goal of this study was to address the prevalence and determinants of psychological well-being in Iranian's PCOS women. The main findings were the high prevalence of depression and anxiety in PCOS women and the reduction of quality of life in patients suffering from psychological impairment, especially in women who were suffering from both anxiety and depression. The prevalence of abnormal depression and mental health disorder varies among studies and this might be a reflection of the differences in methods and tools for screening and diagnosis, population differences, cultural difference and different classification systems. The prevalence of anxiety was high in these PCOS women and about one-third of the participants suffered from anxiety symptoms. This finding is consistent with recent study by Mansson et al. (2008) where they found a significantly elevated life-time incidence of social phobia in PCOS patients (27%; OR: 18.0, 95% CI = 2.2– 144), as well as a trend for an elevated incidence of generalized anxiety disorder (13%; OR: 7.3, 95% CI = 0.86–63).[7] There is evidence to support the concept that anxiety is a risk factor for the development of depressive disorders.[20,21] About 5% of our participants showed elevated HADS depression levels, which is actually somewhat lower than the prevalence of depressive symptoms in previous studies reporting a range of 35 to 67%.[22–24]

Our data indicated that a proportion of PCOS women (i.e. 15%) present with a coexistence of anxiety and depression. The risk of having coexistent depression and anxiety in women with PCOS is unknown. Only in one study found that 15% of PCOS patients showed having coexistent anxiety and depression.[10] Coexisting anxiety in depressed patients may worsen the outcome by increasing the risk of suicide, worsening overall symptoms, conferring a poorer response to treatment, increasing the number of medically unexplained symptoms, and increasing functional disability. Major depression is associated with patient suffering, disability, lost productivity and a higher mortality rate.[25] Untreated anxiety is also associated with high rates of medical co-morbidity and increased utilization of medical health care.[26] The majority of people with anxiety reported substantial interference with their life, a high degree of professional help seeking, and a high use of medication to relieve their symptoms. There is increasing evidence that depression may also be an antecedent to cardiovascular diseases[27] and depression predicts morbidity and mortality in patients with coronary artery disease (CAD).[28] In other hand, Women with PCOS have several cardiometabolic risk factors increasing their overall risk for CVD.

In our study, participants with elevated HADS anxiety and depression levels reported significantly impaired psychological quality of life. This was especially true for those with coexistence anxiety and depression symptoms. It is difficult to know whether it is depression/anxiety that influences lower perceived QOL or that poor perception of QOL increases depression/anxiety. Decreases in psychological, as well as in physical dimensions of quality of life in PCOS patients have previously been reported.[29,30] The determinants of reductions in quality of life in PCOS remain incompletely understood. However, there is converging evidence to suggest that physical aspects of quality of life may be best predicted by obesity and hirsutism, whereas psychological components of quality of life may be more closely related to psychological impairment.[2,31,32] The results confirm Adali's and Hirschberg's findings,[6,32,33] suggesting that treatment of PCOS should tackle both physical and psychological complaints. This is because psychological distress reduces motivation, and yet good motivation is the key to comply with medication and dietary management of PCOS.[23]

Comparison between psychological well-being in women suffering from PCOS showed no significant difference in socio-demographic parameters; therefore, age, marital status, education had no influence on the prevalence of depression or anxiety in women with PCOS or their mental health status. Bhattacharya et al., also noted the same finding.[3]

The current study established that women with menstrual irregularities seemed to be more depressed compared with women with normal menstruation. It has been shown that not only visual features of PCOS such as a higher body weight and an excessive growth of body hair were related to an increased experience of fear of what other people thought about their appearance, but also the absence of their cycle (amenorrhea) was negatively associated with fear of appearance evaluation.[34] The association between fear of negative appearance evaluation and non-visual characteristics might be explained by a reduced feeling of femininity.[35] The importance of menstrual irregularities for Iranian's PCOS women has been demonstrated in previous study and have been found that menstrual problems were the greatest concern reported by the PCOS women.[36] Menstrual irregularities can have important social consequences, especially in many Muslim countries. For example, the tenets of Islam decree that menstruating women cannot pray.[37] Moreover, menstrual irregularities are strongly related with infertility. However, some socio-cultural generalizations are possible: the social pressure to have a child shortly after marriage is strong in the Iran.

The relationship between androgens and mood in women is controversial. Accordingly, we observed that patients with high level of FAI had an elevated risk for anxiety and depression. Conversely, Barry and colleagues[38] failed to find an association between testosterone and mood disturbances in women with PCOS. Accordingly, others also failed to find an association between depression and hormonal and metabolic profile.[39,40] Livadas et al.[39] studied whether anxiety was associated with hormonal and metabolic profile. PCOS women with higher anxiety scores showed significantly elevated HOMA-IR (insulin resistance) and FAI (free androgen excess) values than PCOS women with lower anxiety scores, independently of BMI. In the same line, the relation between greater FAI values and greater levels of anxiety was previously reported by Mansson et al..[7] Perhaps studies with larger samples could elucidate this pattern much better.

It should be noted that this study have certain limitations. The study of patients with PCOS who were attending two private gynecology clinics may limit generalization of the findings to the entire PCOS population. Moreover, all of the patients in this study were married for cultural reasons (sex and infertility) in Iran. Therefore, the results of the present study have to be interpreted with some caution. Another limitation to this study is that the disease- specific scale available to measure the HRQOL of women with PCOS (MPCOSQ) was not used. The generic instrument used for the evaluation of the HRQOL in PCOS in the previous studies was generally the SF-36. However; we accept that this approach might not have been as sensitive for assessing the HRQOL scores when compared with the MPCOSQ. Therefore, the comparison with the MPCOSQ for Iranian PCOS women is necessary for future studies.

Generally, the contribution of individual PCOS symptoms to depression and anxiety risk reported herein should be interpreted with caution since most patients presented with a combination of PCOS symptoms, which may further enhanced the risk for anxiety. Clearly, since we did not analyze the effects of various combinations of clinical symptoms, this aspect of our analysis should be regarded as explorative. Possible selection bias, use of a screening tool alone without further diagnostic evaluation of depression, and lack of direct comparison with a healthy control group should be considered in interpretation of these results.