Skip to main content

Advertisement

SpringerLink
Log in

Depression and Anxiety in Polycystic Ovary Syndrome: Etiology and Treatment

  • Reproductive Psychiatry and Women’s Health (CN Epperson, Section Editor)
  • Published:
Current Psychiatry Reports Aims and scope Submit manuscript

Abstract

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.

Recent Findings

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.

Summary

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. •• 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.

    Article  PubMed  Google Scholar 

  2. 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.

    Article  Google Scholar 

  3. Brassard M, AinMelk Y, Baillargeon JP. Basic infertility including polycystic ovary syndrome. Med Clin N Am. 2008;92:1163–92. xi

    Article  CAS  PubMed  Google Scholar 

  4. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 108: Polycystic ovary syndrome. Obstet Gynecol. 2009;114:936–49.

  5. •• 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.

    Article  PubMed  Google Scholar 

  6. 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.

    Article  PubMed  Google Scholar 

  7. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  8. 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.

    Article  Google Scholar 

  9. • 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.

    Article  CAS  PubMed  Google Scholar 

  10. 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.

    Article  PubMed  Google Scholar 

  11. 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.

    Article  PubMed  Google Scholar 

  12. •• 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.

    Article  PubMed  Google Scholar 

  13. 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.

    Article  Google Scholar 

  14. 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.

    Article  PubMed  Google Scholar 

  15. •• 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.

    Article  PubMed  Google Scholar 

  16. 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.

    Article  PubMed  Google Scholar 

  17. 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.

    Article  PubMed  Google Scholar 

  18. •• 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.

    Article  CAS  PubMed  Google Scholar 

  19. 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.

    Article  PubMed  Google Scholar 

  20. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  21. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  22. 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.

    Article  CAS  PubMed  Google Scholar 

  23. 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.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. 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.

    Article  CAS  PubMed  Google Scholar 

  25. Ferriman D, Gallwey JD. Clinical assessment of body hair growth in women. J Clin Endocrinol Metab. 1961;21:1440–7.

    Article  CAS  PubMed  Google Scholar 

  26. 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.

    Article  PubMed  Google Scholar 

  27. 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.

    Article  PubMed  Google Scholar 

  28. 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.

    Article  PubMed  Google Scholar 

  29. 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.

    Article  PubMed  Google Scholar 

  30. 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.

    Article  PubMed  Google Scholar 

  31. 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.

    PubMed  PubMed Central  Google Scholar 

  32. 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.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  33. 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.

    Article  CAS  PubMed  Google Scholar 

  34. 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.

    PubMed  Google Scholar 

  35. 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.

    Google Scholar 

  36. 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.

    Article  PubMed  Google Scholar 

  37. Belmaker RH, Agam G. Major depressive disorder. N Engl J Med. 2008;358:55–68.

    Article  CAS  PubMed  Google Scholar 

  38. 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.

    Article  CAS  PubMed  Google Scholar 

  39. Benson S, Arck PC, Tan S, et al. Disturbed stress responses in women with polycystic ovary syndrome. Psychoneuroendocrinology. 2009;34:727–35.

    Article  CAS  PubMed  Google Scholar 

  40. Kohler O, Krogh J, Mors O, Benros ME. Inflammation in depression and the potential for anti-inflammatory treatment. Curr Neuropharmacol. 2016;14:732–42.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  41. Duleba AJ, Dokras A. Is PCOS an inflammatory process? Fertil Steril. 2012;97:7–12.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  42. 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.

    Article  Google Scholar 

  43. 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.

    Article  CAS  PubMed  Google Scholar 

  44. 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.

    Article  CAS  PubMed  Google Scholar 

  45. 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.

    Article  CAS  PubMed  Google Scholar 

  46. •• 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.

    Article  PubMed  Google Scholar 

  47. 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.

    Article  Google Scholar 

  48. 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.

  49. 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.

    Article  PubMed  Google Scholar 

  50. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  51. 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.

  52. •• 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.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  53. 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.

    Article  CAS  PubMed  Google Scholar 

  54. 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.

    Article  CAS  PubMed  Google Scholar 

  55. •• 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).

  56. 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.

    Article  PubMed  Google Scholar 

  57. 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.

    Article  Google Scholar 

  58. • 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.

    Article  PubMed  PubMed Central  Google Scholar 

  59. 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.

  60. 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.

    Article  CAS  PubMed  Google Scholar 

  61. 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.

    Article  CAS  PubMed  Google Scholar 

  62. 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.

    Article  CAS  PubMed  Google Scholar 

  63. 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.

    Article  PubMed  Google Scholar 

  64. 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.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  65. 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.

    Article  CAS  PubMed  Google Scholar 

  66. 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.

    Article  CAS  PubMed  Google Scholar 

  67. 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.

    CAS  PubMed  Google Scholar 

  68. 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.

    Article  PubMed  Google Scholar 

  69. 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.

    Article  PubMed  Google Scholar 

  70. 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.

  71. 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.

    Article  Google Scholar 

  72. 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.

    Article  PubMed  Google Scholar 

  73. 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.

Download references

Author information

Authors and Affiliations

  1. Department of Obstetrics and Gynecology, University of Pennsylvania, 3701 Market Street 8th Floor, Philadelphia, PA, 19146, USA

    Laura G. Cooney & Anuja Dokras

Authors
  1. Laura G. Cooney
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Anuja Dokras
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Anuja Dokras.

Ethics declarations

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.

Additional information

This article is part of the Topical Collection on Reproductive Psychiatry and Women’s Health

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

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

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11920-017-0834-2

Keywords

Search

Navigation