Purpose of Review
Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in reproductive age women and is associated with an increased prevalence of depression and anxiety symptoms. This review presents potential mechanisms for this increased risk and outlines treatment options.
Women with PCOS have increased odds of depressive symptoms (OR 3.78; 95% CI 3.03–4.72) and anxiety symptoms (OR 5.62; 95% CI 3.22–9.80). Obesity, insulin resistance, and elevated androgens may partly contribute to this association. Therefore, in addition to established treatment options, treatment of PCOS-related symptoms with lifestyle modification and/or oral contraceptive pills may be of benefit.
Screening for anxiety and depression is recommended in women with PCOS at the time of diagnosis. The exact etiology for the increased risk in PCOS is still unclear. Moreover, there is a paucity of published data on the most effective behavioral, pharmacological, or physiological treatment options specifically in women with PCOS.
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•• Bozdag G, Mumusoglu S, Zengin D, Karabulut E, Yildiz BO. The prevalence and phenotypic features of polycystic ovary syndrome: a systematic review and meta-analysis. Hum Reprod. 2016;31:2841–55. This meta-analysis evaluated the prevalence of PCOS according to the NIH, Rotterdam, and Androgen Excess & PCOS Society (AE& PCOS) criteria. They also compared the prevalence of PCOS by continent.
Rotterdam Consensus. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Hum Reprod. 2004;19:41–7.
Brassard M, AinMelk Y, Baillargeon JP. Basic infertility including polycystic ovary syndrome. Med Clin N Am. 2008;92:1163–92. xi
American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 108: Polycystic ovary syndrome. Obstet Gynecol. 2009;114:936–49.
•• Cooney LG, Lee I, Sammel MD, Dokras A. High prevalence of moderate and severe depressive and anxiety symptoms in polycystic ovary syndrome: a systematic review and meta-analysis. Hum Reprod. 2017a;32:1075–91. This is the largest meta-analysis demonstrating an increased odds of depressive and anxiety symptoms in women with PCOS and the only meta-analysis to evaluate moderate and severe symptoms. They also performed extensive sensitivity analyses and a meta-regression to assess potential etiologies for this association.
Mansson M, Holte J, Landin-Wilhelmsen K, Dahlgren E, Johansson A, Landen M. Women with polycystic ovary syndrome are often depressed or anxious—a case control study. Psychoneuroendocrinology. 2008;33:1132–8.
Sayyah-Melli M, Alizadeh M, Pourafkary N, et al. Psychosocial factors associated with polycystic ovary syndrome: a case control study. J Caring Sci. 2015;4:225–31.
Hung JH, Hu LY, Tsai SJ, et al. Risk of psychiatric disorders following polycystic ovary syndrome: a nationwide population-based cohort study. PLoS ONE [Electronic Resource]. 2014;9:e97041.
• Hart R, Doherty DA. The potential implications of a PCOS diagnosis on a woman’s long-term health using data linkage. J Clin Endocrinol Metab. 2015;100:911–9. This large population based retrospective cohort study showed an increased prevalence of depression and anxiety in hospitalized Australian women with PCOS compared to controls.
Kerchner A, Lester W, Stuart SP, Dokras A. Risk of depression and other mental health disorders in women with polycystic ovary syndrome: a longitudinal study. Fertil Steril. 2009;91:207–12.
Veltman-Verhulst SM, Boivin J, Eijkemans MJ, Fauser BJ. Emotional distress is a common risk in women with polycystic ovary syndrome: a systematic review and meta-analysis of 28 studies. Hum Reprod Update. 2012;18:638–51.
•• Cesta CE, Mansson M, Palm C, Lichtenstein P, Iliadou AN, Landen M. Polycystic ovary syndrome and psychiatric disorders: co-morbidity and heritability in a nationwide Swedish cohort. Psychoneuroendocrinology. 2016;73:196–203. This is the largest registry study (over 24,000 women with PCOS included) demonstrating an increased odds of psychiatric disorders in women with PCOS compared to controls.
Barry JA, Hardiman PJ, Saxby BK, Kuczmierczyk A. Testosterone and mood dysfunction in women with polycystic ovarian syndrome compared to subfertile controls. [Erratum appears in J Psychosom Obstet Gynaecol. 2011 Sep;32(3):164]. J Psychosom Obstet Gynecol. 2011;32:104–11.
Herguner S, Harmanci H, Toy H. Attention deficit-hyperactivity disorder symptoms in women with polycystic ovary syndrome. Int J Psychiatry Med. 2015;50:317–25.
•• Lee I, Cooney LG, Saini S, et al. Increased risk of disordered eating in polycystic ovary syndrome. Fertil Steril. 2017;107:796–802. Women with PCOS had over a fourfold increased odds of disordered eating than controls in this cross-sectional study.
Hollinrake E, Abreu A, Maifeld M, Van Voorhis BJ, Dokras A. Increased risk of depressive disorders in women with polycystic ovary syndrome. Fertil Steril. 2007;87:1369–76.
Luppino FS, de Wit LM, Bouvy PF, et al. Overweight, obesity, and depression: a systematic review and meta-analysis of longitudinal studies. Arch Gen Psychiatry. 2010;67:220–9.
•• Behboudi-Gandevani S, Ramezani Tehrani F, Rostami Dovom M, et al. Insulin resistance in obesity and polycystic ovary syndrome: systematic review and meta-analysis of observational studies. Gynecol Endocrinol. 2016;32:343–53. Insulin resistance is common in both obese and lean women with PCOS.
Smith KJ, Beland M, Clyde M, et al. Association of diabetes with anxiety: a systematic review and meta-analysis. J Psychosom Res. 2013;74:89–99.
Kan C, Silva N, Golden SH, et al. A systematic review and meta-analysis of the association between depression and insulin resistance. Diabetes Care. 2013;36:480–9.
Mezuk B, Eaton WW, Albrecht S, Golden SH. Depression and type 2 diabetes over the lifespan: a meta-analysis. Diabetes Care. 2008;31:2383–90.
Greenwood EA, Pasch LA, Shinkai K, Cedars MI, Huddleston HG. Putative role for insulin resistance in depression risk in polycystic ovary syndrome. Fertil Steril. 2015;104:707–14.e1.
Bromberger JT, Schott LL, Kravitz HM, et al. Longitudinal change in reproductive hormones and depressive symptoms across the menopausal transition: results from the Study of Women’s Health Across the Nation (SWAN). Arch Gen Psychiatry. 2010;67:598–607.
Milman LW, Sammel MD, Barnhart KT, Freeman EW, Dokras A. Higher serum total testosterone levels correlate with increased risk of depressive symptoms in Caucasian women through the entire menopausal transition. Psychoneuroendocrinology. 2015;62:107–13.
Ferriman D, Gallwey JD. Clinical assessment of body hair growth in women. J Clin Endocrinol Metab. 1961;21:1440–7.
Ekback MP, Lindberg M, Benzein E, Arestedt K. Health-related quality of life, depression and anxiety correlate with the degree of hirsutism. Dermatology. 2013;227:278–84.
Pasch L, He SY, Huddleston H, et al. Clinician vs self-ratings of hirsutism in patients with polycystic ovarian syndrome: associations with quality of life and depression. JAMA Dermatol. 2016;152:783–8.
Biringer E, Howard LM, Kessler U, Stewart R, Mykletun A. Is infertility really associated with higher levels of mental distress in the female population? Results from the North-Trøndelag Health Study and the Medical Birth Registry of Norway. J Psychosom Obstet Gynaecol. 2015;36:38–45.
Chen TH, Chang SP, Tsai CF, Juang KD. Prevalence of depressive and anxiety disorders in an assisted reproductive technique clinic. Hum Reprod. 2004;19:2313–8.
Gameiro S, van den Belt-Dusebout AW, Smeenk JM, Braat DD, van Leeuwen FE, Verhaak CM. Women’s adjustment trajectories during IVF and impact on mental health 11–17 years later. Hum Reprod. 2016;31:1788–98.
Sethi P, Sharma A, Goyal LD, Kaur G. Prevalence of psychiatric morbidity in females amongst infertile couples—a hospital based report. J Clin Diagn Res. 2016;10:Vc04–vc7.
Volgsten H, Skoog Svanberg A, Ekselius L, Lundkvist O, Sundstrom PI. Prevalence of psychiatric disorders in infertile women and men undergoing in vitro fertilization treatment. Hum Reprod. 2008;23:2056–63.
Adali E, Yildizhan R, Kurdoglu M, et al. The relationship between clinico-biochemical characteristics and psychiatric distress in young women with polycystic ovary syndrome. J Int Med Res. 2008;36:1188–96.
Davari-Tanha F, Hosseini Rashidi B, Ghajarzadeh M, Noorbala AA. Bipolar disorder in women with polycystic ovarian syndrome (PCO). Acta Medica Iranica. 2014;52:46–8.
Ozenli Y, Haydardedeoglu B, Micozkadioglu I, Simsek E, Bulgan Kilicdag E, Bagis T. Anxiety, depression and ways of coping skills by women with polycystic ovary syndrome: a controlled study. J Turkish-German Gynecol Assoc. 2008;9:190–4.
Shi X, Zhang L, Fu S, Li N. Co-involvement of psychological and neurological abnormalities in infertility with polycystic ovarian syndrome. Arch Gynecol Obstet. 2011;284:773–8.
Belmaker RH, Agam G. Major depressive disorder. N Engl J Med. 2008;358:55–68.
Gallinelli A, Matteo ML, Volpe A, Facchinetti F. Autonomic and neuroendocrine responses to stress in patients with functional hypothalamic secondary amenorrhea. Fertil Steril. 2000;73:812–6.
Benson S, Arck PC, Tan S, et al. Disturbed stress responses in women with polycystic ovary syndrome. Psychoneuroendocrinology. 2009;34:727–35.
Kohler O, Krogh J, Mors O, Benros ME. Inflammation in depression and the potential for anti-inflammatory treatment. Curr Neuropharmacol. 2016;14:732–42.
Duleba AJ, Dokras A. Is PCOS an inflammatory process? Fertil Steril. 2012;97:7–12.
Anglin RE, Samaan Z, Walter SD, McDonald SD. Vitamin D deficiency and depression in adults: systematic review and meta-analysis. Br J Psychiat. 2013;202:100–7.
Ju SY, Lee YJ, Jeong SN. Serum 25-hydroxyvitamin D levels and the risk of depression: a systematic review and meta-analysis. J Nutr Health Aging. 2013;17:447–55.
Krul-Poel YH, Snackey C, Louwers Y, et al. The role of vitamin D in metabolic disturbances in polycystic ovary syndrome: a systematic review. Eur J Endocrinol. 2013;169:853–65.
Moran LJ, Teede HJ, Vincent AJ. Vitamin D is independently associated with depression in overweight women with and without PCOS. Gynecol Endocrinol. 2015;31:179–82.
•• Goodman NF, Cobin RH, Futterweit W, Glueck JS, Legro RS, Carmina E. American association of clinical endocrinologists, American College of Endocrinology, and Androgen Excess and PCOS Society disease State clinical review: guide to the best practices in the evaluation and treatment of polycystic ovary syndrome—part 2. Endocr Pract. 2015a;21:1415–26. This extensive and up-to-date review provides evidenced-based guidelines on PCOS evaluation and treatment.
Goodman NF, Cobin RH, Futterweit W, Glueck JS, Legro RS, Carmina E. American association of clinical endocrinologists, American College of Endocrinology, and Androgen Excess and PCOS Society disease State clinical review: guide to the best practices in the evaluation and treatment of polycystic ovary syndrome—part 1. Endocrine Pract. 2015b;21:1291–300.
Galletly C, Moran L, Noakes M, Clifton P, Tomlinson L, Norman R. Psychological benefits of a high-protein, low-carbohydrate diet in obese women with polycystic ovary syndrome--a pilot study. Appetite. 2007;49:590–3.
Thomson RL, Buckley JD, Lim SS, et al. Lifestyle management improves quality of life and depression in overweight and obese women with polycystic ovary syndrome. Fertil Steril. 2010;94:1812–6.
Nidhi R, Padmalatha V, Nagarathna R, Amritanshu R. Effect of holistic yoga program on anxiety symptoms in adolescent girls with polycystic ovarian syndrome: a randomized control trial. Int J Yoga. 2012;5:112–7.
Stener-Victorin E, Holm G, Janson PO, Gustafson D, Waern M. Acupuncture and physical exercise for affective symptoms and health-related quality of life in polycystic ovary syndrome: secondary analysis from a randomized controlled trial. BMC Complement Altern Med. 2013;13:131.
•• Dokras A, Sarwer DB, Allison KC, et al. Weight loss and lowering androgens predict improvements in health-related quality of life in women with PCOS. J Clin Endocrinol Metab. 2016;101:2966–74. This is a secondary analysis of a three-arm randomized controlled trial comparing changes in quality of life and the prevalence of depressive and anxiety symptoms after women with PCOS received one of three interventions: oral contraceptive pills (OCPs), a lifestyle (LS) modification program, or a combined OCP and LS.
Clayton WJ, Lipton M, Elford J, Rustin M, Sherr L. A randomized controlled trial of laser treatment among hirsute women with polycystic ovary syndrome. Br J Dermatol. 2005;152:986–92.
Kashani L, Omidvar T, Farazmand B, et al. Does pioglitazone improve depression through insulin-sensitization? Results of a randomized double-blind metformin-controlled trial in patients with polycystic ovarian syndrome and comorbid depression. Psychoneuroendocrinology. 2013;38:767–76.
•• Cooney LG, Milman LW, Hantsoo L, et al. Cognitive behavioral therapy improves weight loss and quality of life in women with polycystic ovary syndrome: a randomized clinical trial. 2017b. Unpublished data. This unpublished study is the first RCT to demonstrate significant weight loss in women with PCOS, depression and overweight/obesity who receive cognitive behavioral therapy (CBT).
Stefanaki C, Bacopoulou F, Livadas S, et al. Impact of a mindfulness stress management program on stress, anxiety, depression and quality of life in women with polycystic ovary syndrome: a randomized controlled trial. Stress. 2015;18:57–66.
Peckmezian T, Hay P. A systematic review and narrative synthesis of interventions for uncomplicated obesity: weight loss, well-being and impact on eating disorders. J Eating Dis. 2017;5:15.
• Haqq L, McFarlane J, Dieberg G, Smart N. Effect of lifestyle intervention on the reproductive endocrine profile in women with polycystic ovarian syndrome: a systematic review and meta-analysis. Endocr Connect. 2014;3:36–46. This meta-analysis of seven studies demonstrates significant improvements in the laboratory profile of women with PCOS who received lifestyle interventions.
Moran LJ, Hutchison SK, Norman RJ, Teede HJ. Lifestyle changes in women with polycystic ovary syndrome. Cochrane Database Syst Rev. 2011(1):1-63. https://doi.org/10.1002/14651858.CD007506.pub3.
Galletly C, Moran L, Noakes M, Clifton P, Tomlinson L, Norman R. Psychological benefits of a high-protein, low-carbohydrate diet in obese women with polycystic ovary syndrome—a pilot study. Appetite. 2007;49:590–3.
Cinar N, Harmanci A, Demir B, Yildiz BO. Effect of an oral contraceptive on emotional distress, anxiety and depression of women with polycystic ovary syndrome: a prospective study. Hum Reprod. 2012;27:1840–5.
Zethraeus N, Dreber A, Ranehill E, et al. A first-choice combined oral contraceptive influences general well-being in healthy women: a double-blind, randomized, placebo-controlled trial. Fertil Steril. 2017;107:1238–45.
Harris-Glocker M, Davidson K, Kochman L, Guzick D, Hoeger K. Improvement in quality-of-life questionnaire measures in obese adolescent females with polycystic ovary syndrome treated with lifestyle changes and oral contraceptives, with or without metformin. Fertil Steril. 2010;93:1016–9.
Ladson G, Dodson WC, Sweet SD, et al. Effects of metformin in adolescents with polycystic ovary syndrome undertaking lifestyle therapy: a pilot randomized double-blind study. Fertil Steril. 2011a;95:2595–8 e1-6.
Ladson G, Dodson WC, Sweet SD, et al. The effects of metformin with lifestyle therapy in polycystic ovary syndrome: a randomized double-blind study. Fertil Steril. 2011b;95:1059–66 e1-7.
Rosenblat JD, Kakar R, Berk M, et al. Anti-inflammatory agents in the treatment of bipolar depression: a systematic review and meta-analysis. Bipolar Disord. 2016;18:89–101.
Colle R, de Larminat D, Rotenberg S, et al. PPAR-gamma agonists for the treatment of major depression: a review. Pharmacopsychiatry. 2017a;50:49–55.
Colle R, de Larminat D, Rotenberg S, et al. Pioglitazone could induce remission in major depression: a meta-analysis. Neuropsychiatr Dis Treat. 2017b;13:9–16.
Qaseem A, Barry MJ, Kansagara D, Clinical Guidelines Committee of the American College of P. Nonpharmacologic versus pharmacologic treatment of adult patients with major depressive disorder: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2016;164:350–9.
Work Group on Major Depressive Disorder. Practice guideline for the treatment of patients with major depressive disorder. 2010. http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf.
Cuijpers P, Cristea IA, Karyotaki E, Reijnders M, Huibers MJ. How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence. World Psychiat. 2016;15:245–58.
Rofey DL, Szigethy EM, Noll RB, Dahl RE, Lobst E, Arslanian SA. Cognitive-behavioral therapy for physical and emotional disturbances in adolescents with polycystic ovary syndrome: a pilot study. J Pediatr Psychol. 2009;34:156–63.
Teede HJ, Misso ML, Deeks AA, Moran LJ, Stuckey BG, Wong JL, et al. Guideline Development G: Assessment and management of polycystic ovary syndrome: summary of an evidence-based guideline. Med J Aust. 2011;195:S65-112.
Conflict of Interest
Laura G. Cooney and Anuja Dokras declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
This article is part of the Topical Collection on Reproductive Psychiatry and Women’s Health
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Cooney, L.G., Dokras, A. Depression and Anxiety in Polycystic Ovary Syndrome: Etiology and Treatment. Curr Psychiatry Rep 19, 83 (2017). https://doi.org/10.1007/s11920-017-0834-2