Background
Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorder having most impact on women of reproductive age group, affecting their quality of life (HRQOL) and psychological well-being.
Objective
This paper aims to determine QOL among women affected with PCOS attending a multidisciplinary clinic using PCOSQ tool and its association with socio-economic status, phenotypes, anxiety, depression and metabolic comorbidities and evaluate the coping strategies adapted by these women.
Design
Retrospective study.
Setting
Integrated multidisciplinary PCOS clinic.
Patient(s)
Two hundred and nine women diagnosed with PCOS as per Rotterdam criteria.
Results
Infertility was an important condition for reduced HRQOL and psychological morbidity across all socio-economic status and phenotypes. The poor psychological status and obesity were identified as determinants of HRQOL among women affected with PCOS. Those who suffered from anxiety, depression and showed lower HRQOL used emotional maladaptive coping strategies.
Conclusion
Results reveal that HRQOL of PCOS women is worsened in the presence of comorbidities. Maladaptive and disengagement coping strategies used by women may worsen their psychological status. Holistic assessment of comorbidities and its management can help improve HROL of affected women. Personalised counselling based on the assessment of coping strategies used by women could empower women to cope better with PCOS.
Keywords : Polycystic ovary syndrome · Quality of life · Coping strategies · Anxiety · Depression
Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorder affecting women from adolescence to menopause impacting reproductive health and general wellbeing [1]. Studies on PCOS in India report varied prevalence ranging from 3.7 to 22.5% [2]. Most common symptoms of PCOS are menstrual irregularities, infertility, hirsutism, acne vulgaris, acanthosis nigricans and androgenetic alopecia [1]. Many women diagnosed with PCOS also present with features of metabolic syndrome (MS) [3].
There are various reports linking specific features of PCOS with decreased psychological well-being. This is often due to negative body image not conforming to the societal norms of physical and cosmetic appearance and hence lowering the selfesteem of these women [4]. Irrespective of severity of symptoms, studies have shown that this may result in anxiety and depression and have a negative impact on health-related quality of life (HRQOL) in women with PCOS including adolescents [5–12]. Hence, guidelines [13, 14] recommend screening for psychological well-being in all women with PCOS. Not much is known about how women in India cope with PCOS and how it affects their psychological well-being and HRQOL. Studies on HRQOL and PCOS have used generalised tools such as SF 36 [5, 6, 9] and WHOQOL BREF [10, 12]. However, Polycystic Ovarian Syndrome Questionnaire (PCOSQ) is a very specific tool [15] that has been developed based on signs and symptoms affecting women with PCOS. Very few studies in Indian context have used PCOSQ [16, 17] and studied their association with phenotypes and associated morbidities.
Coping strategies (CS) form an important link between a stressful situation and the resulting psychological response of the person towards it [18]. An illness and its subsequent sequelae can bring about stressful reactions in people [19]. The process of successful or unsuccessful coping can affect their health behaviour, choices and outcomes including psychological well-being and HRQOL. [19, 20]. Successful use of adaptive CS helps in reducing psychological problems in women with PCOS [18, 21].
This paper aims to determine HRQOL among women affected with PCOS attending a multidisciplinary clinic using PCOSQ tool and its association with socio-economic status (SES), phenotypes, anxiety, depression and MS and evaluate the CS adapted by these women.
Clinicians often are more objective in treating PCOS such that they focus on clinical and laboratory parameters to treat physical health parameters. This paper aims to highlight the importance of addressing HRQOL and CS that are less addressed in clinical practice.
HRQOL is a very subjective concept and is determined by a number of measurable and non-measurable aspects of how a woman, her family and society perceives the symptoms and associated comorbidities. Many tools have been used to measure HRQOL. Qualitative interviews with women with PCOS have demonstrated that generic questionnaires can underestimate the full impact of PCOS on their HRQOL, as they do not explore issues specific to PCOS. [27] However, PCOSQ is specifically developed tool to assess HRQOL in PCOS women.
Indian studies using SF 36 and WHO BRIEF [12, 28] to evaluate HRQOL in women with PCOS have also reported lower HRQOL scores across different domains like social and interpersonal relationships, physical, environmental, financial, psychological, etc., as compared to healthy controls. Having used PCOSQ, we have reported reduced HRQOL in women with PCOS in domains like emotion, hair, menstruation, weight and infertility which are more specific to PCOS. Our findings reveal infertility affected HRQOL the most. A strong association is reported between infertility and emotional well-being of women with PCOS in another study done in North India [17] using PCOSQ. It is obvious as infertility is a socially stigmatising problem less addressed through the public health system in India. This finding is also supported by other studies using SF 36 and WHO BRIEF [10, 12, 28]. The WHO BRIEF study also found that patients with hirsutism had lower HRQOL scores [10]. Study done in Hyderabad [16] using PCOSQ reported menstruation affected HRQOL the most, different from our finding, probably due to majority of the study population being unmarried girls, and pregnancy not being a priority. This reveals that health priorities differ in different age groups and affect different dimensions or domains of HRQOL.
Our finding, that higher the SES, better the HRQOL, resonates with the findings published from Poland [29]. This is one very strong pointer of how PCOS is a social and economic issue irrespective of the phenotypes women present with as also seen in a study from Iran [30].
Poor HRQOL, psychological status such as anxiety, depression, and use of improper CS are interdependent factors that need a holistic assessment and care using a multidisciplinary approach. The meta-analysis [4] published in 2012 on prevalence of anxiety in PCOS women suggested that hirsutism, obesity and infertility are triggers for psychological distress, unfortunately it did not include any studies from India that have also reported prevalence of psychological disorders [12, 27, 31] among women with PCOS much higher as compared to controls [12, 27, 32]. Our analysis reported that about two-third (68.9%) women had anxiety and depression, which are the most commonly reported psychological disorders associated with PCOS [8]. However, the prevalence was higher than that reported in another study from Mumbai, India, that used HADS tool and reported 38.6% prevalence for anxiety disorders and 25.7% for depressive disorders [12]. The prevalence of anxiety and depression in our subjects may be higher as a large proportion (88%) of our participants were suffering from infertility unlike the study in Mumbai, where infertility was reported by less than a quarter of total sample. Another Indian study from Kashmir [32] reported prevalence of generalised anxiety disorder to be 15.5% and 23% had depression on using a DSM-IV tool.
The presence of anxiety and depression was correlated with specific PCOSQ domains which has not been reported earlier, to our knowledge. Results revealed that women with anxiety and depression scored significantly poor on all the PCOSQ domains and total HRQOL score, as compared to those who did not. Further analysis revealed that among all independent variables, obesity and psychological status affected HRQOL significantly. As expected, infertility greatly affected psychological status. Thus, addressing infertility is an important strategy to facilitate PCOS women improve their HRQOL.
Research studies have found individuals using problemoriented CS are better suited to handle stressful situations and that has positive effect on the HRQOL [33]. Negative impact of stress can reduce individual’s resilience, and leave long-term adverse health impacts, thus emphasising that CS adopted by individuals is critical [34, 35].
Our findings suggest that mostly a combination of both engagement and disengagement CS was used. However, those who had lower HRQOL and anxiety and depression used disengagement CS, which was statistically significant similar to a study done in Turkey [36]. Some of the earlier studies report disengagement CS to be positively correlated with psychological morbidity [21, 37] and inversely correlated with the HRQOL [21, 38].
Women generally tend to use emotion focused CS [34, 39]. Improper CS severely affects the HRQOL of women affected with PCOS [37]. High level of stress and a feeling that the situation is not under their control makes it difficult to use problem focused CS [40]. Given that our study population constituted of a large number of women with infertility, which is a very stressful condition, emotion focused disengagement CS approach was seen extensively used in our study.
This study has the limitation due to the absence of a control group. Intervention studies using multidisciplinary approach are needed to assess impact of various therapeutic drugs, biofeedback strategies, cognitive therapies and involvement of marital partners, families and social support groups to provide an enabling environment that could help avert these morbidities among women affected with PCOS.
Ethics Approval All necessary ethical approvals were obtained from NIRRCH Ethical Committee for Clinical Studies and use of retrospective data. The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments.
Conflict of interest The authors have no conflicts of interest to declare that are relevant to the content of this manuscript.
Consent to Participate Informed written consent for participation in study was obtained from all individual participants included in the study.
