Polycystic Ovarian Syndrome–Related Depression in Adolescent Girls: A Review

Abstract

Polycystic ovarian syndrome (PCOS), a common endocrinal disorder of reproductive age characterized by heterogeneous complications, is nowadays prevailing among females at adolescent stage. Infrequent or prolonged menstrual periods, excess hair growth, acne, and obesity can occur in women with PCOS. In adolescents, infrequent or absence of menstruation may raise chances for this condition. The increased prevalence of PCOS among general population throughout the world is found to be 5%–10% in the women of reproductive age, and about 40% women with PCOS experience depression, particularly young girls. The exact cause of PCOS is unknown. Early diagnosis and treatment along with weight loss may reduce the risk of long-term complications. Depression and anxiety are common in women with PCOS but are often overlooked and therefore left untreated. Along with the physical disturbances, many mental problems are also associated with PCOS. Therefore, PCOS not only has problems associated with reproduction but also has associated crucial metabolic and psychological health risks with increasing age of the patients. Because of the increased number of cases with PCOS around the world in present times, with prominent symptom of, specifically, depression at the adolescent stage, it is important to highlight the disease.

INTRODUCTION

Polycystic ovarian syndrome (PCOS) is the most common endocrine disorder in women, having 15%–20% prevalence among infertile women.[1] It occurs in 6%–10% of women of reproductive age with a higher prevalence in obese women.[2] It is a genetic condition that is complex with multiple phenotypes and various appearances. The highly occurring heterogeneous syndrome can be characterized by polycystic ovaries (PCO), ovulatory dysfunction, and clinical and/or biochemical androgen excess. Patients with PCOS are more prone to serious health troubles, particularly reproductive dysfunctions. Metabolic disturbances are prevalent in two-thirds of women with PCOS, which may lead to the high risk of cardiovascular and type-2 diabetes mellitus in them.[3] Psychosocial problems arise in patients with PCOS, as shown by various investigators,[4,5] particularly due to obesity, excessive body hairs, infertility, and changes in the physical appearances. As a whole, different reasons for psychological stress, particularly among the adolescent girls associated with PCOS, is discussed in this article with probable management and treatment overview to cope with the PCOS stress for young girls.

MATERIALS AND METHODS

A literature research was performed on Google Scholar and Medline databases. Various studies on metformin were analyzed. The search terms used were Polycystic ovarian syndrome, Depression, and Adolescent.

RESULTS

Prevalence

Studies reviel the increased prevalence of PCOS among the general population throughout the world, which ranges from 5% to 10%[6] in women of reproductive age, and about 40% women with PCOS experience depression,[7] particularly the young girls. The rate of PCOS in South-Western United States was found to be 4%. The incidence screened out to be 9.13% in Indian adolescents.[8] As per the National Institute of Health, the rate of PCOS increases from 6.5% to 6.8% in adult reproductive-aged woman worldwide.[9]

Pathophysiology of the disease

The pathophysiology of PCOS is contributed by both the genetic and the environmental factors.[10] Genetically, it can be explained as an increase in the levels of ovarian hyperandrogenism[11] due to the influence of luteinizing hormone (LH) and insulin. Elevated LH level that ultimately causes an increase in the production of androgens from cells, called theca cells in young girls and women having PCOS, may provide an insight of aberrant secretion levels of Gonadotropin-Releasing Hormone.[12] The environmental factors primarily include obesity, nutrition or eating disorders,[13] and insulin resistance.[14]

Moreover, the pathophysiology of depression and mental stress during PCOS is linked to various changes that include psychological changes such as high activity of pro-inflammatory markers and immune system during stress.[15]

Signs and symptoms

Patients with PCOS usually express symptoms from puberty.[10] It may include transient postmenarcheal anovulation and multicystic ovaries. The general three criteria featuring PCOS established by PCOS consensus were; clinical hyperandrogenism, oligo/amenorrhea, and PCO identified in ultrasonography, which are the definitions, not sufficient to diagnose PCOS in adolescents, where PCOS even if present can be identified till adulthood. Oligomenorrhea exists if menstrual cycle lasts for above 35 days whereas acne, androgenic alopecia, or hirsutism are the clinical symptoms of hyperandrogenism.[16,17,18]

The etiology of PCOS can be contributed to both genetic predisposition and lifetime factors.[19] The mechanism of genetic disposition in the development of PCOS is well established, but environmental factors may include sedentary lifestyle, imbalanced diet that may result in insulin resistance, and obesity, which are potential factors in the development of PCOS.[20] Although women having PCOS have advanced chances of developing depression than women who are not affected by PCOS,[21] obesity aggravates the condition. Obesity usually coexists with PCOS. The 40%–60% of women who have PCOS are obese.[22] In patients with PCOS, the major determinant of metabolic phenotype is obesity, whereas teen juveniles are observed as protected from the metabolic disturbances of PCOS.[23] The clinical and biochemical phenotype of PCOS are greatly influenced in the case of genetically predisposed individuals.[24]

Diagnosis

The criteria for the diagnosis of PCOS in adults are also applicable to the adolescents as the PCOS’s diagnosis criteria in an adolescent are not defined yet.[21] Some simple clinical tests can be performed to diagnose PCOS as suggested by PCOS consensus workshop group. These include; 1) the level of testosterone should be checked in girls who showed symptoms of high androgen levels 2) the levels of Follicle-Stimulating Hormone (FSH), LH, prolactin, and estradiol should be measured in the case of oligo- or amenorrhea (anovulation); and 3) the transabdominal scanning of ovaries by ultrasound can prove helpful in an adolescent with menstrual disturbances or hyperandrogenism. Routine 75g oral glucose tolerance test in an adolescent with body mass index (BMI) of >30 kg·m⁻² is advisable.

Mental stress among adolescent with PCOS

PCOS-related mental stress is well studied by Himelein et al.,[25] which indicates the symptoms of PCOS mostly affecting the patients include increased androgen levels, menstrual disturbances, infertility,[5] obesity, hirsutism, or alopecia, but nowadays behavioral scientists start observing significant levels of mental stress in patients with PCOS,[26] particularly among the young girls. This may be because young girls are more concerned about their physiology and physical health during adolescence. One of the studies reveals clear stress symptoms explicated in a group of women who are having PCOS than the women who are not affected by PCOS.[27] Depression and stress are the high-risk factors among the patients with PCOS along with the impaired metabolic and reproductive features. This high level of depression and anxiety in the patients with PCOS may be due to various reasons such as high BMI and demoralization faced by patients with PCOS in the society, which when severe may lead to social withdrawal.[12] The clinical symptoms of PCOS, i.e., hyperandrogenism and infertility, add significantly to the severity of the conditions.[28]

In addition, studies carried out by Hollinrake et al.[21] determined some more reasons for increased risk of depression among patients with PCOS than in control group. Patients with family history of infertility and depression along with high BMI factor and sleep disturbances[29] and exhaustion followed by decreased interest in daily chores and appetite changes are the most common factors of depression among the patients with PCOS.

Interesting findings were obtained when clinical/biochemical parameters were correlated with stress in young women with PCOS.[30] These studies reveal significantly higher levels of hirsutism and testosterone in the group of women with PCOS along with the higher BMI, LH/FSH, and Waist-to-Hip Ratio (WHR). Depression and emotional stress were analyzed with Turkish version of the Beck Depression Inventory and 12-item General Health Questionnaire. Both parameters were found to be high in the patients with PCOS than that of the control group, which when correlated with the clinical/biochemical parameters depict the positive relation between them. Among all the factors in patients with PCOS, obesity is the most prominent feature causing an elevation in emotional stress level and depression among adolescent girls than BMI, and WHR also causes a notable increase in the levels of mental stress and depression. Factors such as high sympathetic activity, elevated cortisol levels, and low level of serotonin are associated with both, insulin and depression.[19] It is reported that different factors of PCOS to develop depression in a woman will lead to induce higher insulin resistance and impaired fasting glucose than undepressed PCOS women.[31] There are several types of researches that reported a correlation between levels of serum androgen and depression scores.[32] It is observed that due to the appearance of physical characteristics of hyperandrogenism, which includes obesity, cystic acne, hirsutism, hair loss (alopecia), and seborrhea, more negative self-image with low self-esteem is induced, which cause high depression levels and psychological distress among women with PCOS.[19,23,24,25,26,27,28,29,30,31,32,33,34]

PCOS depression management and treatment in adolescents

According to the recent management guidelines by Consensus on treatment of PCOS, the counseling related to the lifestyle changes, i.e., obesity control, daily walk, prevent smoking and alcohol consumption, clinical symptoms (menses irregularities) particularly in young girls, insulin resistance before medical treatment can produce positive outcomes[35] by lowering the stress level in PCOS patients. Standard metformin treatment in PCOS cases if practiced regularly for 6 months can help to reduce various reproductive, physiological, and psychological problems.[36]

Several stress management interventions are also suggested to normalize Hypothalamic-Pituitary-Adrenal (HPA) axis at a normal pace, which may act as stressors by exaggerating Sympathetic Nervous System response in women with PCOS.[37] It may include cognitive behavioral therapy and relaxation at the stage when standard metformin treatment fails to produce the expected stress relief in patients with PCOS.[38]

The reason of distress along with the hirsutism among adolescents with PCOS is mostly due to the excess levels of androgens. Antiandrogen therapy can be carried out (if necessary) along with the cosmetic management[39] (provided that hair removal method is authorized). The major challenge is the prevention of long-term complications of PCOS. The strong control of diet and an active lifestyle can effectively reduce the risk of diabetes in at-risk adults.[40]

DISCUSSION

Polycystic ovarian syndrome is a chronic, heterogeneous disorder of endocrine system with prominent features of androgens, menstrual disturbances, and depression. It is a leading cause of pregnancy complications and infertility among women and causes depression among young girls. The reason for the extreme mental stress and depression in an adolescent with PCOS is due to the appearance of embarrassing symptoms such as hirsutism, obesity, and acne during adolescence.[4]

Obesity was pointed to be the major factor causing depression and emotional stress among adolescents with PCOS,[22] which needs to be managed both psychologically and clinically to overcome mental stress in patients. Thus, it is concluded that major psychological and behavioral intervention approaches that are dominantly useful in relieving depression in patients with PCOS particularly at the adolescent stage are quality sleep, improved lifestyle (healthy diet and preventing sedentary lifestyle), and regular exercise. These psychosocial techniques prove useful in reducing stress and depression through weight loss and physiological maintenance.

It is now an established fact that maintenance of healthy and active lifestyle can support to lessen both the physiological and the psychological symptoms.[41] So, it is recommended that stress in women having PCOS is treated primarily psychosocially and clinically in a later stage, which is also a more economical and promising option.

CONCLUSIONS

PCOS is a chronic, heterogeneous disorder of endocrine system with prominent features of androgens, menstrual disturbances, and depression. Depression and stress are the high-risk factors among the patients along with the impaired metabolic and reproductive features. Obesity was pointed to be the major factor causing depression and emotional stress among adolescents.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.