Polycystic Ovarian Syndrome (PCOS) is the most common endocrine-related dysfunction in women of reproductive age (1). It is also the most common cause of infertility due to the absence of ovulation. Many women are not diagnosed as having PCOS until they experience issues with infertility (2). PCOS is considered to be a genetic disease affecting around 7% of women in this age group worldwide (3).
Women with this syndrome likely have one or more of the following three conditions: lack of ovulation which leads to irregular or no menstrual periods, high androgen levels which lead to the development of male characteristics (e.g., hirsutism or excess unwanted hair growth), fluid-filled sacs (cysts) on one or both ovaries (polycystic literally means many cysts) (2, 4). Other problems linked to PCOS include obesity and weight gain, acne, sleep apnea, diabetes and insulin resistance, heart disease and hypertension, metabolic syndrome including hyperlipidemia, and mood related disorders (1-4).
A recent systematic review and meta-analysis in the Journal of Neuropsychiatric Disease and Treatment further explores the association between anxiety, depression and PCOS (3). The authors included original reports where the prevalence of psychiatric disorders was compared between women with an established diagnosis of PCOS and those without PCOS. Six studies qualified for this analysis; all reported on rates of depression and five reported on rates of anxiety.
The paper concluded that depression and anxiety are more prevalent in patients with PCOS. Women with PCOS were nearly three times as likely to report anxiety symptoms compared to women without PCOS (odds ratio (OR) =2.76; 95% Confidence Interval (CI) 1.26-6.02; p=0.011). Similarly, patients with PCOS were more likely to have depressive symptoms compared to women without PCOS (OR=3.51; 95% CI 1.97-6.24; p<.001). Of note, the studies were performed in clinical settings in four countries including the United States, Turkey, Australia, and Brazil (3).
Certainly, more robust and conclusive research is needed in order to better explore the association between PCOS and mental health related issues. The authors of this paper propose that some mechanisms underlying such a correlation could include social, psychological, and neurobiological factors. As an example, the authors cite previous research showing that alterations in body image can cause psychosocial stressors in women with PCOS (3, 5).
The possible neurophysiologic etiology discussed in this paper includes HPA (hypothalamus- pituitary-adrenal) dysregulation leading to an excess of androgen production and lack of cortisol level regulation. Supporting this hypothesis is a neuroimaging study which demonstrated greater activity in the prefrontal cortex and ventral anterior cingulate cortex, areas of the brain which are important to emotional processing and are modulated by levels of cortisol, in patients with PCOS as compared to healthy individuals (6). What is not noted in this paper is the likely link between PCOS and dysregulation of the HPG (hypothalamus-pituitary-gonadal) axis. The HPG axis is involved in controlling levels of the neurosteroids estrogen and progesterone. The link between estrogen and serotonin, as well as progesterone and its metabolite allopregnanolone, are a subject of many current studies in women of reproductive age with mood disorders.
In short, patients with PCOS seem to have a higher prevalence of depressive and anxiety related symptoms. Clinically this is important as patients with PCOS should be screened for symptoms of co-morbid anxiety and depression, and vice versa. A patient with history of obesity and anxiety, for example, should be asked about symptoms suggestive of PCOS (e.g., hirsutism, acne, irregular menses, history of ovarian cysts). Often the treatment of this syndrome needs a multidisciplinary collaboration between different providers, such as primary care providers, reproductive health care providers, endocrinologists, and mental health professionals.
Edwin Raffi, MD
- Palomba, S., Santagni, S., Falbo, A., & La Sala, G. B. (2015). Complications and challenges associated with polycystic ovary syndrome: current perspectives. International journal of women’s health, 7, 745.
- Blay, S.L., Aguiar, J.V.A. and Passos, I.C., 2016. Polycystic ovary syndrome and mental disorders: a systematic review and exploratory meta-analysis. Neuropsychiatric Disease and Treatment, 12, p.2895.
- ESHRE, T.R. and Group, A.S.P.C.W., 2004. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertility and sterility, 81(1), pp.19-25.
- Himelein, M.J. and Thatcher, S.S., 2006. Depression and body image among women with polycystic ovary syndrome. Journal of health psychology, 11(4), pp.613-625.
- Marsh, C.A., Berent-Spillson, A., Love, T., Persad, C.C., Pop-Busui, R., Zubieta, J.K. and Smith, Y.R., 2013. Functional neuroimaging of emotional processing in women with polycystic ovary syndrome: a case-control pilot study. Fertility and sterility, 100(1), pp.200-207.