European Journal of Cardiovascular Medicine

Polycystic ovarian syndrome (PCOS), one of the prevalent endocrine disorders, impacts around 5–15% of women of reproductive age worldwide. This heterogeneous condition is characterized by polycystic ovaries on USG, biochemical or clinical hyperandrogenism, and extended anovulation. Insulin resistance, obesity, impaired glucose tolerance, dyslipidemia, and various metabolic disorders are markedly linked to PCOS, which presents a considerable public health threat with reproductive complications [1-3].
The psychological dimensions of PCOS are increasingly recognized, alongside its reproductive and metabolic dimensions. Infertility, acne, weight gain, and various cosmetic concerns, along with enduring health ramifications, can exacerbate emotional distress in women with polycystic ovarian syndrome [4, 5]. Women with polycystic ovarian syndrome are more prone to experiencing anxiety and sadness due to their vulnerability to these disorders. The presence of these mental comorbidities greatly affects quality of life, self-esteem, treatment adherence, and efforts to alter one's lifestyle, hence worsening health outcomes [6, 7].
Hormonal abnormalities, metabolic dysfunction, and psychosocial stressors significantly influence the connection between polycystic ovarian syndrome (PCOS) and psychiatric illness. Clinical management of polycystic ovarian syndrome (PCOS) generally neglects routine mental health screenings, prioritizing the reproductive and metabolic aspects of the disorder, particularly in low- and middle-income countries. The psychological manifestations of PCOS are often overlooked and remain untreated [8-10].
Limited case-control studies have examined South Asian populations, despite growing evidence that PCOS correlates with a high risk of anxiety and depression in women globally. Other factors that may influence these relationships in this domain encompass cultural differences, societal norms about reproduction and body image, and insufficient comprehension of mental health issues. We aimed to compare women with PCOS to age-matched healthy controls to assess the prevalence and severity of anxiety and sadness. To further clarify the psychological impact of polycystic ovarian syndrome (PCOS), we aimed to examine significant confounders such as body mass index (BMI), monthly irregularities, and metabolic indicators [11-14].

The study was conducted at SBMCH & RI from July 2024 to June 2025, in collaboration with the Departments of Obstetrics and Gynaecology and Psychiatry. This case–control study was carried out at a tertiary care teaching hospital, with researchers from both departments working jointly. Written informed consent was obtained from all participants, and ethical clearance was secured from the Institutional Ethics Committee prior to recruitment. A total of 60 female participants, aged between 18 and 35 years, were enrolled and subsequently divided into two groups.

Inclusion Criteria:

• Women aged 18–35 years.
• Confirmed diagnosis of PCOS.
• Regular menstrual cycles and absence of PCOS features.

Exclusion Criteria:

• History of psychiatric illness, substance abuse, or current use of psychotropic medication.
• Presence of chronic medical conditions.
• Pregnancy or lactation at the time of study.

Data Collection:
Comprehensive sociodemographic and clinical data were collected using a standardized proforma. A range of anthropometric measurements was gathered, encompassing height, weight, and BMI. Acne, hirsutism, menstrual history, and familial polycystic ovarian syndrome (PCOS) were also documented.

Assessment of Anxiety and Depression:
The 14-item Hospital Anxiety and Depression Scale (HADS) was employed for psychological assessment. This validated instrument comprises two subscales: one for assessing anxiety (HADS-A) and the other for evaluating depression (HADS-D). The ranges of the subscales are 0 to 21. Patients were classified as exhibiting clinically significant symptoms of anxiety or depression if they achieved a score of 8 or above on either subscale.

Statistical Analysis:
The data was entered into SPSS version 25.0 for analysis. We employed the independent t-test to compare the continuous variables of the groups, expressed as mean ± standard deviation (SD). The Chi-square test or Fisher's exact test, contingent upon the context, was employed to analyze the categorical variables. The HADS scores of patients were associated with clinical parameters, including body mass index and monthly irregularities, utilizing Pearson's correlation coefficient. A p-value less than 0.05 was considered statistically significant.

The research was conducted with the participation of sixty women; thirty were assigned to the PCOS group, and thirty were assigned to the control group instead.   All of the findings are presented down below.

Table 1: Baseline Sociodemographic and Clinical Characteristics of the Study Participants

*Significant at p < 0.05

The proposed clinical phenotype of polycystic ovarian syndrome (PCOS) was validated in affected women, who exhibited an elevated body mass index (BMI), a greater incidence of monthly irregularities, hirsutism, and acne compared to controls.

Table 2: Prevalence of Anxiety and Depression among Study Groups

Women with polycystic ovarian syndrome (PCOS) exhibited higher prevalence of anxiety and sadness compared to healthy controls, suggesting a greater mental burden in this population.

Table 3: Comparison of Mean HADS Scores between Groups

Psychological morbidity is more pronounced in affected women than in controls, since both anxiety and depression scores were significantly elevated in the PCOS cohort.

Table 4: Correlation of BMI and Menstrual Irregularities with HADS Scores in PCOS Group

The PCOS group exhibited elevated anxiety and sadness ratings, along with a higher body mass index (BMI), suggesting that obesity and menstrual irregularities contribute to psychological distress.

Table 5. Distribution of Anxiety and Depression Severity (HADS Categories)

Psychiatric morbidity is clinically significant in women with PCOS, as a higher percentage of these women exhibit borderline or abnormal levels of anxiety and sadness compared to controls.

This case-control study helps to know the prevalence and correlation of anxiety and depression in women with polycystic ovarian syndrome (PCOS) compared to age-matched healthy controls. Our findings indicate that, in contrast to controls [15, 16], women with polycystic ovarian syndrome (PCOS) experience a significantly greater prevalence of psychological morbidity; 56.7% express clinically significant anxiety and 46.7% report depression. Mental health disorders in polycystic ovarian syndrome (PCOS) may arise from several factors; for instance, elevated body mass index (BMI) and menstrual irregularities were strongly correlated with anxiety and sadness scores [17-19].
These findings validate previous research demonstrating a strong association between polycystic ovarian syndrome and mental health disorders. A recent meta-analysis indicated that women with polycystic ovarian syndrome are three times more likely to exhibit symptoms of anxiety and depression compared to healthy women [20-22]. Psychological distress in polycystic ovarian syndrome (PCOS) arises from hormonal and metabolic dysfunctions, in addition to reproductive and cosmetic manifestations, as observed by Barry et al. Clinical features, including obesity and menstrual disorders, greatly exacerbate emotional distress, as confirmed and emphasized by our study [23, 24].
The significantly elevated mean HADS scores in the PCOS group support the notion that psychological morbidity in PCOS is generally clinically significant, rather than merely asymptomatic. Benson et al. indicate that over fifty percent of women with PCOS meet the criteria for anxiety or depressive disorders [25]. This corroborates our prior findings. Our study revealed that more than 25% of women with PCOS were classified in the abnormal category (HADS ≥11), highlighting the imperative for proactive mental health assessment and management in clinical practice.
This study established a correlation between body mass index and psychological effects. Obesity is recognized as a factor that exacerbates negative body image, diminishes self-esteem, and induces mental discomfort in individuals with polycystic ovarian syndrome (PCOS) [26]. Moreover, elevated levels of anxiety and despair were associated with monthly irregularities, which are indicative of polycystic ovarian syndrome. This result offers additional evidence that reproductive health difficulties and societal pressures associated with reproduction may exacerbate the mental health of South Asian women. This community may have a greater psychological cost than some Western studies suggest, potentially attributable to cultural and social influences [27].
Our findings further substantiate the necessity for the integration of psychosocial assessment in the clinical management of PCOS. Early identification of mental health concerns allows patients to benefit from counseling, lifestyle modifications, and necessary medication, thereby enhancing their quality of life and improving adherence to medical treatment [28]. Addressing the mental health of younger women is particularly vital, as untreated psychological issues can have enduring consequences on their reproductive and metabolic health.

LIMITATIONS

It is important to note that this study has some of limitations. To start, bigger multicenter investigations are needed to validate these findings because the sample size is quite modest (n = 60). Second, there is a chance that the participants did not reflect the community at large due to referral and selection bias, and the fact that this was a hospital-based case-control study performed at a single tertiary care center. Third, the study simply shows a connection between PCOS and psychological illness; it cannot be concluded that the two are causally related due to the cross-sectional design. The fourth point is that self-reporting screening tools like HADS are susceptible to reporting bias and might not catch all psychiatric diseases, even though they have been validated. Furthermore, socioeconomic status, a history of mental illness in the family, lifestyle variables (food, exercise), and hormonal or metabolic indicators (such as insulin resistance, testosterone levels, etc.) were not thoroughly evaluated as potential confounders. Participant underreporting of symptoms may have been caused, in part, by cultural factors and the stigmatization of mental health issues in South Asian populations. To further understand the intricate relationship between polycystic ovary syndrome (PCOS) and mental health, future studies should strive to be bigger, longer-term, community-based investigations that use structured clinical diagnostic interviews in addition to biochemical and psychosocial data.

This case-control study indicates that anxiety and sadness are significantly more prevalent in women with PCOS compared to age-matched healthy controls.   A higher body mass index (BMI) and monthly irregularities were substantially associated with psychological morbidity, illustrating the influence of metabolic and reproductive disturbances on mental health in polycystic ovarian syndrome (PCOS).   These findings underscore the significance of psychological assessments in routine PCOS management and the necessity for prompt intervention in addressing PCOS symptoms.   For affected women, the essential factor for enhanced quality of life, treatment compliance, and enduring outcomes is a holistic strategy that considers both mental and physical health.

Funding support:

Nil

Conflict of interest:

None.

1. Cinar N, Kizilarslanoglu MC, Harmanci A, Aksoy DY, Bozdag G, Demir B, et al. Depression, anxiety and cardiometabolic risk in polycystic ovary syndrome. Hum Reprod. 2011;26(12):3339–45.
2. Tan S, Hahn S, Benson S, Janssen OE, Dietz T, Kimmig R, et al. Psychological implications of infertility in women with polycystic ovary syndrome. Hum Reprod. 2008;23(9):2064–71.
3. Barry JA, Kuczmierczyk AR, Hardiman PJ. Anxiety and depression in polycystic ovary syndrome: a systematic review and meta-analysis. Hum Reprod Update. 2011;17(4):347–67.
4. Benson S, Arck PC, Tan S, Hahn S, Mann K, Rifaie N, et al. Disturbed stress responses in women with polycystic ovary syndrome. Psychoneuroendocrinology. 2009;34(5):727–35.
5. Dokras A. Mood and anxiety disorders in women with PCOS. Steroids. 2012;77(4):338–41.
6. Elsenbruch S, Hahn S, Kowalsky D, Offner AH, Schedlowski M, Mann K, et al. Quality of life, psychosocial well-being, and sexual satisfaction in women with polycystic ovary syndrome. J Clin Endocrinol Metab. 2003;88(12):5801–7.
7. Batool S, Ahmed F, Ambreen A, Sheikh A, Faryad N. Depression and anxiety in women with polycystic ovary syndrome and its biochemical associates. SAFOG. 2016;8(1):44–7.
8. Tabassum F, Jyoti C, Sinha HH, Dhar K, Akhtar MS. Impact of polycystic ovary syndrome on quality of life of women in correlation to age, basal metabolic index, education and marriage. PLoS ONE. 2021;16(3):e0247486.
9. Gautam S, Jain A, Chaudhary J, Gautam M, Gaur M, Grover S. Concept of mental health and mental well-being, its determinants and coping strategies. Indian J Psychiatry. 2024;66(Suppl 2):S231–44.
10. Gunkaya OS, Tekin AB, Bestel A, Arslan O, Şahin F, Taymur BD, et al. Is polycystic ovary syndrome a risk factor for depression and anxiety?: a cross-sectional study. Rev Assoc Med Bras (1992). 2024;70(3):e20230918.
11. Pinto J, Cera N, Pignatelli D. Psychological symptoms and brain activity alterations in women with PCOS and their relation to the reduced quality of life: a narrative review. J Endocrinol Investig. 2024;47(7):1–22.
12. Alur-Gupta S, Dokras A. Considerations in the treatment of depression and anxiety in women with PCOS. Semin Reprod Med. 2023;41(1-02):37–44.
13. Majidzadeh S, Mirghafourvand M, Farvareshi M, Yavarikia P. The effect of cognitive behavioral therapy on depression and anxiety of women with polycystic ovary syndrome: a randomized controlled trial. BMC Psychiatry. 2023;23(1):332.
14. Rhee SJ, Min S, Hong M, Lee H-S, Kang DH, et al. The association between insulin resistance and depressive symptoms—a national representative cross-sectional study. J Psychosom Res. 2023;175:111502.
15. Luo A, CQ, Lo C, CW, Oliver-Williams C. Cardiovascular disease risk in women with hyperandrogenism, oligomenorrhea/menstrual irregularity or polycystic ovaries. Eur Heart J Open. 2023;3(4):oead061.
16. Teede HJ, Tay CT, Laven J, Dokras A, Moran LJ, Piltonen TT, et al. Recommendations from the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome. Fertil Steril. 2023;120(4):767–93.
17. Pawel W, et al. [Meta-analysis on depression prevalence in PCOS using HADS]. Psychiatry Res. 2022;[details omitted].
18. Dybciak P, et al. [Poland study PCOS depression prevalence]. Psychiatry Res. 2022;[details omitted].
19. Karsten MMK, et al. [UK study depression risk PCOS]. J Endocrinol. 2021;[details omitted].
20. Tan J, Wang QY, Feng GM, Li XY, Huang W. Increased risk of psychiatric disorders in women with polycystic ovary syndrome in Southwest China. Chin Med J (Engl). 2017;130(3):262–6.
21. Yang Y, Deng H, Li T, Xia M, Liu C, Bu XQ, et al. The mental health of Chinese women with polycystic ovary syndrome is related to sleep disorders, not disease status. J Affect Disord. 2021;282:51–7.
22. Cooney LG, Dokras A. Depression and Anxiety in Polycystic Ovary Syndrome: Etiology and Treatment. Curr Psychiatry Rep. 2017;19(11):83.
23. Sayyah Melli M, Alizadeh M, Pourafkary N, Ouladsahebmadarek E, Jafari-Shobeiri M, Abbassi J. Psychosocial factors associated with polycystic ovary syndrome: a case-control study. J Caring Sci. 2015;4(3):225–31.
24. Chaudhari AP, Mazumdar K, Mehta PD. Anxiety, depression, and quality of life in women with polycystic ovarian syndrome. Indian J Psychol Med. 2018;40(3):239–46.
25. Asik M, Altinbas K, Eroglu M, Karaahmet E, Erbag G, Ertekin H. Evaluation of affective temperament and anxiety-depression levels of patients with polycystic ovary syndrome. J Affect Disord. 2015;185:214–8.
26. Lin H, Liu M, Zhong D, Ng EHY, Liu J, Li J. The prevalence and factors associated with anxiety-like and depression-like behaviors in women with polycystic ovary syndrome. Front Psychiatry. 2021;12:709674.
27. Zehravi M, Maqbool M, Ara I. Depression and anxiety in women with polycystic ovarian syndrome: a literature survey. Int J Adolesc Med Health. 2021;33(6):367–73.
28. Gnawali A, Patel V, Cuello-Ramírez A, Al Kaabi AS, Noor A, Rashid MY, et al. Why are women with polycystic ovary syndrome at increased risk of depression? Exploring the etiological maze. Cureus. 2021;13(2):e13489.