Abstract
Polycystic ovary syndrome is a common condition that affects ovarian function and the process of hormone generation. There are a variety of symptoms that people can have, including a higher risk for mental illness and psychiatric disorders. Research has shown that people with PCOS have higher rates of mental disorders compared to their counterparts. There are also differences between adults and adolescents, them being mostly self-esteem and sexual function. It is also variable within the population with different studies showing contrasting results. This literature review shows the link between mental health and polycystic ovary syndrome in both adults and adolescents.
Keywords: bipolar, depression, anxiety, mental health, PCOS
Introduction
Polycystic ovary syndrome (PCOS) is typically characterized as a common condition that impacts how a person’s ovaries work and their hormone production within six to twelve percent of the population. PCOS occurs when the ovaries create an excessive amount of hormones, androgens specifically, which leads to a hormonal imbalance. There are many different side effects that people may have, including but not limited to; irregular menstrual cycles, missed periods, unpredictable ovulation, infertility, and polycystic ovaries. Polycystic ovaries contain a large number of follicles which are underdeveloped sacs that eggs grow inside. While these follicles are harmless, PCOS prevents these sacs from releasing their eggs, so ovulation doesn’t take place in cases of polycystic ovaries.
With PCOS, there is variety within the disease with different phenotypes. There has been more research on the characterization of the phenotypes in recent years and researchers have split it up into four types by the Rotterdam criteria. They are titled A, B, C, and D and have criteria that separate them. Both A and B are the “classic” PCOS types, with them having the menstrual dysfunction associated with PCOS along with being two-thirds of the population with PCOS. They also have symptoms related to insulin resistance, higher blood insulin levels, and risk for metabolic syndromes, as well as others. Type C is “ovulatory PCOS” which means that they show intermediate levels of androgen, insulin, atherogenic lipids, and percentages of metabolic disease comparatively to type A and B. Type D is the “non hyperandrogenic PCOS” which constitutes lower levels of endocrine and metabolic dysfunction compared to all the other types.
There is currently no cure for any of the four phenotypes despite its commonness, but there are ways to treat the symptoms that arise in these cases. One of these such symptoms that has arisen was the prevalence of psychiatric disorders. Recent studies have investigated the link between mental illness and polycystic ovary syndrome. This literature review dives into research with both adolescents and adults in countries all over the world.
Adults with PCOS
Adulthood starts right after adolescence, at twenty years of age and on. Most adults with PCOS have figured out that they have it by the start of adulthood, but some develop symptoms in their early twenties and thirties. One side effect, as had been established, was an increased chance of developing a mental disorder. According to the World Health Organization, one in every eight people has a mental illness (World Health Organization 2022). The differences between the majority of people and people with PCOS are many.
One study that was done investigated the rate of psychiatric disorders in a sample of PCOS patients. 72 women who were in treatment were the subjects, and the PCOS was confirmed with ultrasounds and then underwent evaluation with the Diagnostic and Statistical Manual for Mental Disorders (Fourth Edition). It turns out that 41 patients (57%) showed symptoms of at least one mental illness, with 78% being mood disorders. The most common diagnoses were major depression (26.4%) and bipolar disorder (11.1%) (Rassi et al. 2010, 601). Percentages for the general population for mood disorders and more specifically major depressive disorder and bipolar disorder are 8.4% and 1.4%, respectively, in adults. This preliminary study really shows the disproportionate rate of mental illnesses in people with PCOS.
Another study was done to measure the prevalence of Axis I and II psychiatric disorders in people with and without PCOS. They took 73 people both with and without (controls) PCOS and conducted structured clinical interviews with them. It was found that both types of disorders (Axis I: 28.8% vs 15.1%; Axis II: 23.3% vs 9.6%) were significantly more prevalent in patients with PCOS. The most common were social phobias, generalized anxiety disorder, and avoidant personality disorder (Sahingöz et al. 2013, 509). This study mostly focused on anxiety but sheds light on the different types of psychiatric disorders found in people with PCOS and how they are sorted.
Similarly, yet not, a study was conducted on the differences between various phenotypes of PCOS in terms of sexual function, depression, anxiety, and quality of life scale. It shows the different categories, just for PCOS. There were 192 women with PCOS and 50 controls that filled out questionnaires (Female Sexual Function Index, Hospital Depression, Anxiety Scale, and the 12-Item Short Form Health Survey) all the same. The results showed that type B PCOS had the highest scores in anxiety and depression, while they also had the lowest scores in questions about sexual function (Bahadori et al. 2022). As described, there was a large difference between all phenotypes and the control groups in terms of sexuality and sexual dysfunction. This study really exemplifies the difference not just between controls and people with PCOS, but within different phenotypes of PCOS as well.
The population of adults with PCOS has also been studied to see not just disorders, but the events leading up to them, like adverse childhood experiences (ACES). There was one study that cross-referenced survey data taken in ‘89-’95 with ages 19-26 from people with and without self-diagnosed PCOS. There were 760 with and, 7910 without, but the women with PCOS reported significantly higher rates of psychiatric disorders and adverse childhood events (19.3% to 9.2%) (Tay et al. 2020, 3). There was a clear divide between ACEs and mental disorders, comparatively between people with and without PCOS. This meant that people with PCOS experienced more ACES and were more commonly diagnosed with mental disorders.
All these studies show a significant increase in rates of mental disorders in adults with PCOS. Even those rates, though, contain a plethora of variation between different phenotypes and other categories.
Adolescents with PCOS
Adolescence has been confined to the ages of ten to nineteen years of age by most governments around the globe. PCOS researchers have agreed that it mostly starts during puberty with their first menstrual cycle in these years of growing up. In these years of development, there has been a significant number of people with mental illness. According to the World Health Organization, as many as one in seven adolescents have a mental disorder, contributing to a wide-scale problem (World Health Organization 2021). Children with PCOS, however, have vast differences from ‘healthy’ adolescents.
One study was done to evaluate self-reported anxiety and depression in children with PCOS, along with a rare congenital disease called Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS). There were 49 participants, 22 with PCOS and 5 with MRKHS, that were evaluated with the Beck Depression Inventory and State-Trait Anxiety Inventory to measure depression and anxiety, respectively. It showed that the group with PCOS was 1.08 times more likely to have higher anxieties and three times more likely to have mild depression (Laggari et al. 2009, 86). Despite the small sample size, there is enough evidence in this study to suggest there is a connection between depression, anxiety, and PCOS. There is also a large link to it being more common for depression to show than anxiety in adolescents with PCOS, shown by this study.
Another study showed a clear link between depression self-esteem and body perception. The researchers wanted to see the difference between girls with PCOS in body perception, self-esteem, and psychiatric disorders, with their ‘healthy’ peers. 50 girls aged 12-18 with PCOS were with 37 girls the same age that did a semi-structured interview and asked to do questionnaires (the Rosenberg Self-Esteem Scale, Children’s Depression Inventory, and the Body Image Scale) about the subject matters. The results showed that the girls with PCOS had significantly higher rates of disorders (32% to 13.5%), with major depressive disorder being the most common, and had lower self-esteem and body image (Sari, Celik, and Uzun Cicek 2020, 4).
Going off the last study, there’s one similar to it with goals and objectives like it. The researchers’ goals were to evaluate psychiatric disorders, health-related quality of life, and self-esteem within a group of girls. The participants were 13-18, 28 with and 31 without PCOS, and undertook an interview with a psychiatrist using official scales (Schedule for Affective Disorders and Schizophrenia for School Age Children, Pediatric Quality of Life Inventory, and the Rosenberg Self-Esteem Inventory) to measure various aspects of mental and emotional health. The results showed that the psychiatric diagnosis rate was higher in the girls with PCOS (+21%), but the other indicators, quality of life and self-esteem, showed no significant relationship with each other compared to the controls (Çoban et al. 2019, 3). Compared to the previous study, it shows that psychiatric disorders are more common, but the data disagrees about self-esteem, with one study showing no relation and one showing lower rates of self-esteem (Sari, Celik, and Uzun Cicek 2020, 4), interestingly enough.
A thing that contributes to the development of these prevalent psychiatric disorders are experiences that contribute to this. One such qualitative study wanted to investigate the psychological experiences of girls with PCOS. They did in-depth interviews, focus groups, and field notes from 18 adolescents, between the ages of 15 and 21, and 15 healthcare providers. The information extracted was placed into three main categories (experiences with disease symptoms, experiences with disease complications, and experiences of treatment) and then extrapolated to many further subcategories. The results showed that adolescents with PCOS were found to be exposed to multiple concerns about their psychological health (Noroozi et al. 2020). This shows some of the roots of mental illnesses that may not have been shown previously.
All four of these studies may show different things, but have one thing in common, the higher rates of which people with PCOS have mental illnesses/disorders. There have been many trains of thought about why this may be but none can be certain. Some think it’s due to the symptoms and complications that come with PCOS that lead to mental disorders. Others think that the hormonal imbalance associated with PCOS could cause psychiatric disorders as well. Further research needs to be done to definitively say what the cause is.
Conclusion
Polycystic ovary syndrome is a common condition that not only can affect a person’s physical traits and health but their mental health as well. Both adults and adolescents, with any phenotype, experience higher rates of comorbid psychiatric disorders compared to their ‘healthy’ peers. Despite the difficulty in accurately diagnosing younger children with PCOS, those who have been diagnosed show similar rates and experiences to their older counterparts. Individuals with PCOS have higher chances of developing a mental illness, contrasting with the rest of the population, according to the research. Further research needs to be done about specific mental disorders and their prevalence in each different phenotype as well as the cause of the link between mental disorders and PCOS. There could also be the role of genetics along with mental health and PCOS.
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