Psychological Distress and Fatigue in Polycystic Ovarian Syndrome: A Pilot Study

Abstract

Background:

Polycystic ovarian syndrome (PCOS) is a complex endocrine disorder affecting both physical and psychological health in women of reproductive age. While its metabolic and reproductive symptoms are well-documented, fatigue remains an underrecognised yet significant concern. Psychological distress, including anxiety, depression and stress, may contribute to fatigue in women with PCOS, either directly or by influencing sleep disturbances. While insomnia is commonly reported in this population, this study primarily focuses on fatigue and its association with psychological distress, with sleep disturbances considered as a secondary factor requiring further exploration.

Aim:

This study aims to investigate the association between psychological distress (anxiety, depression and stress) and fatigue in women with PCOS. In addition, it explores whether sleep disturbances show any association with fatigue, providing insights into factors that may contribute to fatigue severity in this population.

Settings and Design:

This is a cross-sectional pilot study conducted in a university outpatient department.

Materials and Methods:

A total of 52 women, diagnosed with PCOS were included in this cross-sectional study. Data collection involves scoring of fatigue by administering the fatigue severity scale (FSS) and insomnia severity index (ISI) for insomnia and components of psychological distress (stress, depression and anxiety) using the Depression Anxiety Stress Scale-21.

Statistical Analysis Used:

Data were analysed using IBM SPSS version 25. Pearson correlation coefficients were used to explore bivariate relationships between fatigue and independent variables. Statistical significance was set at P < 0.05.

Results:

The findings revealed significant associations between FSS and psychological distress, particularly anxiety (r = 0.507, P = 0.038) and depression (r = 0.595, P = 0.012). In addition, insomnia (ISI) showed the strongest correlation with fatigue (r = 0.705, P = 0.002), indicating that sleep disturbances may further exacerbate fatigue in women with PCOS.

Conclusion:

This study highlights a strong association between psychological distress, insomnia and fatigue in women with PCOS. The findings suggest that higher levels of anxiety, depression and sleep disturbances contribute significantly to fatigue severity, emphasising the need for integrated psychological and sleep management strategies in PCOS care. Further research with larger cohorts and longitudinal designs is necessary to establish causal relationships and develop targeted interventions for improving overall well-being in this population.

INTRODUCTION

Polycystic ovarian syndrome (PCOS) is the most prevailing female endocrine and metabolic disorder, affecting 3.7%–22.5% of women in India.[1] While the condition is often associated with physical symptoms such as irregular menstrual cycles, polycystic ovarian morphology and obesity, its psychological effects such as anxiety, depression, stress and insomnia are increasingly recognised.[2,3,4,5] Despite the growing acknowledgment of psychological distress and insomnia in PCOS, its potential contribution to fatigue remains poorly understood.

Fatigue is a complex phenomenon that can result from an illness, general tiredness or a lack of exercise.[6] Fatigue is not traditionally highlighted among PCOS symptoms, yet studies indicate it frequently accompanies the condition.[7,8] Fatigue has been increasingly recognised in chronic diseases, including metabolic and reproductive disorders such as PCOS.[6,7] Research indicates that women with PCOS have higher levels of fatigue, sleep disturbances and psychological distress, suggesting a possible interrelationship.[8,9,10]

Understanding these associations is essential, as fatigue can significantly impair daily functioning, occupational performance and quality of life. If psychological distress and insomnia are identified as major contributors to fatigue, targeted psychological and sleep interventions may play an important role in alleviating fatigue-related complications in PCOS. This study aims to examine the association between psychological distress (anxiety, depression and stress), insomnia and fatigue in women with PCOS, providing valuable insights into the broader implications of psychological health in PCOS management.

MATERIALS AND METHODS

Ethical approval

This study was conducted according to the ethical guidelines in the Helsinki Declaration (2013 edition). Ethical approval was obtained from the institutional human ethics committee, and the study was registered in the Clinical Trial Registry of India (CTRI/2024/ 07/070982). Before the study, informed consent was obtained from all participants, and strong confidentiality procedures were taken.

Study design and participants

This prospective observational study included women with PCOS (n = 52) diagnosed on the basis of modified Rotterdam criteria. Participants were recruited between August 2024 and December 2024 from the outpatient physiotherapy department of a state government university, with additional recruitment from university students.

Selection criteria

Women aged 18–34 years residing in North India with stable vital signs were included, as this age group represents the early reproductive years, ensuring a stable presentation of PCOS-related symptoms for accurate assessment.[11] PCOS diagnosis was confirmed using the modified Rotterdam criteria, requiring at least two of the following: Oligo/anovulation, hyperandrogenism or polycystic ovarian morphology, verified through clinical history, hormonal assays, and ultrasound findings. Only participants with a PCOS diagnosis for at least 1 year were included to ensure diagnostic stability. Participants with irregular menstrual cycles (≥35 days apart or ≤8 cycles per year) and body mass index between 18.5 and 29.9 kg/m² were included.

Those who had engaged in structured physical activity within the last 6 months, had a history of smoking, pregnancy, lactation or medication use affecting pulmonary function or psychological outcomes, or had blood pressure >139/89 mmHg or heart rate >100 bpm was excluded.

Sample size

The sample size for the prospective observational study was calculated using the formula:

n = (z)² p (1–p)/d² where, z = confidence level (1.96), p is the estimated prevalence (22.5%) and d is the margin of error (5%).

Using these parameters, the calculated sample size required for the study is 268 participants. To account for potential dropouts or non-responses, a 10% additional margin was added, bringing the final required sample size to 298 participants.

For this preliminary analysis, data from the first 52 participants were collected to ensure methodological consistency and identify potential recruitment challenges before advancing to full-scale data collection and analysis. These preliminary findings serve to validate the study methodology and assess feasibility while laying the groundwork for the full-scale study with a calculated sample size of 298 participants.

Data collection

Data collection for this study was carefully structured to gather comprehensive demographic, clinical and psychological data. Participants’ demographic details, including age, marital status and education were recorded using a standardised form. Clinical information, such as the duration of PCOS diagnosis and menstrual history, was documented. Resting vital signs, including blood pressure and heart rate, were measured using calibrated automated devices to ensure consistency and accuracy.

The psychological distress was assessed using the Depression Anxiety Stress Scale-21 (DASS-21). This validated scale has 21 items separated into three subscales, and participants rate each item on a 4-point Likert scale. Scores were classified into severity categories to better understand participants’ psychological condition. Fatigue severity was assessed using the Fatigue Severity Scale (FSS), a widely used nine-item scale rated on a 7-point Likert scale, which measures the impact of fatigue on participants’ daily functioning. Insomnia was evaluated using the seven-item insomnia severity index (ISI), a seven-item measure of the degree of sleep issues including trouble falling or staying asleep, early awakening and associated discomfort. Classifying the overall ISI results helped one to establish the clinical degrees of insomnia severity.

To ensure data quality and reliability, all assessments were conducted in a controlled environment under the supervision of trained researchers following standardised protocols. Data were thoroughly reviewed at the point of collection to ensure completeness and accuracy, minimising the potential for errors. Questionnaires were administered in the participants’ preferred language, either Hindi or English, to facilitate better comprehension and ensure the validity of their responses.

Statistical analysis

Data were analysed using IBM SPSS Statistics for Windows, Version 25.0. (IBM Corp Armonk, NY). The normality of the data was established by the Kolmogorov–Smirnov test. Pearson correlation coefficients were calculated to explore the association between fatigue, insomnia, stress, anxiety and depression. Statistical significance was established at P < 0.05, and all analyses were performed using two-tailed tests to provide a reliable interpretation of data.

RESULTS

The descriptive analysis provides an overview of the demographic and clinical characteristics of the study participants, as summarised in Table 1.

Table 1.

Descriptive statistics of study participants

Variables (n=52)		Mean±SD/n (%)		Range
Demographics
Age (years)		21.29±2.97		18–34
Marital status (single/married)		39 (75.0)/13 (25.0)		-
Education level
High school		12 (23.1)		-
Undergraduate		28 (53.8)		-
Post-graduate		12 (23.1)		-
Anthropometric measures
Weight (kg)		58.41±13.69		45–90
Height (cm)		157.77±6.74		145–172
BMI (kg/m2)		23.48±5.27		18.5–29.9
Clinical characteristics
Duration of PCOS diagnosis (years)		3.1±1.5		1–6
Age at PCOS diagnosis (years)		18.2±2.4		12–25
Menstrual cycle length (days)		42.3±7.5		35–60
Presence of oligomenorrhoea		47 (90.4)		-
Presence of amenorrhoea		5 (9.6)		-
Psychological and sleep measures
ISI		14.53±5.6		-
FSS		42.35±10.7		-
Anxiety		11.71±4.1		-
Depression		9.35±5.7		-
Stress		10.88±5.1		-

ISI=Insomnia Severity Index, FSS=Fatigue Severity Scale, BMI=Body mass index, PCOS=Polycystic ovarian syndrome, SD=Standard deviation

The analysis revealed significant relationships among fatigue, insomnia and psychological distress measures, as shown in Table 2. Fatigue severity was significantly associated with insomnia, anxiety and depression, indicating a strong interconnection between physical and psychological factors.

Table 2.

Correlation between fatigue and independent variables

Dependent variable Fatigue (FSS) (n=52)		Independent variables
		Insomnia (ISI)		Depression (DASS-21)		Anxiety (DASS-21)		Stress (DASS-21)
Correlation coefficient (r)		0.705**		0.595*		0.507*		0.176
P		0.002		0.012		0.038		0.5

*Correlation is significant at the 0.05 level (two-tailed), **Correlation is significant at the 0.01 level (two-tailed). DASS-21=Depression Anxiety Stress Scale-21, ISI=Insomnia Severity Index, FSS=Fatigue Severity Scale

These findings indicate significant relationships among the variables, emphasising the need for integrated management strategies that consider both physical and psychological health considerations.

DISCUSSION

Fatigue in PCOS is an underrecognised yet debilitating symptom that can significantly impair daily functioning, productivity and overall well-being. The findings of this study indicate that psychological distress, particularly anxiety and depression, is significantly associated with fatigue severity in women with PCOS. In addition, insomnia emerged as a strong contributor to fatigue, suggesting that sleep disturbances may further intensify the psychological and physiological burden of the condition. These results reinforce the need for a comprehensive, multidisciplinary approach to PCOS management that integrates both psychological and lifestyle interventions.

The association between psychological distress and fatigue aligns with previous research indicating that anxiety, depression and chronic stress can contribute to heightened physiological exhaustion and reduced energy levels. Zangeneh et al. reported that psychological distress is highly prevalent in women with PCOS, often exacerbated by body image concerns, metabolic complications and reproductive health anxieties.[9] Similarly, Damone et al. highlighted the role of anxiety and depression as key contributors to overall disease burden, interacting in ways that intensify fatigue and emotional exhaustion.[12]

Despite being historically overlooked, fatigue is now recognised as a critical concern even in younger women with PCOS. Research by Ee et al. and Tandoğan et al. highlights that psychological distress, hormonal imbalances and sleep disturbances contribute to early-onset fatigue, significantly affecting academic performance, work productivity and overall quality of life.[7,8] Investigating fatigue in this population is imperative, as early intervention could mitigate long-term complications and prevent the worsening of symptoms over time.

The current study extends these findings by confirming that higher levels of anxiety and depression are linked to increased fatigue severity, highlighting the need for early psychological screening and targeted interventions in PCOS management.

Beyond psychological distress, insomnia emerged as a significant contributor to fatigue severity in this study. Sleep disturbances, particularly difficulty initiating and maintaining sleep, are well-documented in women with PCOS, largely driven by hormonal imbalances, stress and dysregulation of the hypothalamic-pituitary-adrenal axis.[10] Fernandez et al. reported that over 60% of women with PCOS experience sleep disturbances, which, in turn, exacerbate fatigue and impair daily functioning.[10] The strong correlation between insomnia and fatigue severity in this study reinforces these findings, highlighting poor sleep quality as a potential mediator between psychological distress and fatigue. While previous studies have examined sleep disruptions and metabolic dysregulation in PCOS, limited research has specifically explored how psychological distress, insomnia and fatigue interact, making this study a significant contribution to the existing literature.

The interim analysis was conducted to ensure methodological consistency, assess feasibility and identify recruitment challenges before full-scale data collection. Given the subjective nature of psychological distress and fatigue assessments, it was essential to validate data collection procedures and recruitment strategies, ensuring methodological rigor and data reliability for detecting associations in women with PCOS.

The interplay between psychological distress, sleep disturbances and fatigue in PCOS is likely bidirectional. The findings of Kite et al. support this, demonstrating that women with PCOS who experience higher anxiety levels are more likely to suffer from disrupted sleep patterns, leading to worsened fatigue symptoms.[13] However, while this study establishes strong associations between these variables, the cross-sectional nature of the study design limits the ability to determine causality. Future longitudinal studies are needed to explore whether psychological distress directly causes fatigue or if other physiological factors mediate this relationship.

This study has several strengths that make it a valuable contribution to understanding the psychological and physical burdens in women with PCOS. The use of validated tools such as the DASS-21, FSS and ISI ensured consistent and comprehensive assessments of psychological distress, fatigue and insomnia. By focusing on a well-defined cohort of clinically diagnosed women, the findings are directly applicable to the target population. In addition, exploring the relationships among insomnia, fatigue and psychological distress addresses an underexamined area in PCOS research.

This study has several limitations. The cross-sectional design restricts the ability to establish causal relationships, while the small sample size may limit generalisability and statistical power. In addition, as the study was conducted in a single geographic region, cultural and regional variations in PCOS-related psychological and physical symptoms may not be fully captured. Unmeasured confounders, including hormonal fluctuations, lifestyle behaviours, socioeconomic status and broader sleep-related factors, may have influenced the observed associations

The findings highlight the need to address fatigue as a significant yet often overlooked symptom in PCOS, influenced by psychological distress and sleep disturbances. Given the strong associations observed, routine fatigue assessments should be integrated into PCOS management alongside psychological and sleep evaluations. Addressing fatigue through targeted interventions, such as cognitive-behavioural therapy for stress and insomnia, structured exercise programs and lifestyle modifications, may help alleviate symptom burden and improve overall functional capacity and quality of life. Healthcare providers should adopt a multidisciplinary approach that considers both physiological and psychological contributors to fatigue in PCOS.

Future studies should prioritise longitudinal designs to establish causal relationships between psychological distress, sleep disturbances and fatigue in women with PCOS. Investigating the roles of hormonal and metabolic mediators in these relationships could provide deeper insights into underlying mechanisms. In addition, intervention studies examining the effectiveness of combined psychological and lifestyle strategies in reducing fatigue and improving mental health outcomes are needed. Such research would help develop evidence-based practices for comprehensive PCOS management.

CONCLUSION

This study identifies fatigue as a prevalent and clinically relevant symptom in PCOS, demonstrating significant associations with psychological distress (anxiety, depression and stress) and insomnia. These findings emphasise the necessity for a comprehensive, integrative approach that considers both psychological and sleep-related factors in the management of fatigue in women with PCOS. The study’s cross-sectional design and limited sample size restrict causal inferences; therefore, longitudinal research with larger, more diverse cohorts is warranted to establish causal pathways and develop targeted interventions. Addressing fatigue as a core component of PCOS management could significantly enhance patient outcomes, daily functioning and overall well-being in this population.

Author contributions

All authors contributed to the conceptualisation, study design, data collection, analysis and manuscript preparation. The final version of the manuscript was reviewed and approved by all authors.

Conflicts of interest

There are no conflicts of interest.

Data availability statement

The datasets generated and analysed during the current study are available upon reasonable request from the corresponding author.

Funding Statement

Nil.