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Body image, self-esteem and depressive symptomatology in women with polycystic ovary syndrome/ Polikistik over sendromu olan kadinlarda beden algisi, benlik saygisi ve depresif belirtiler.

Introduction

Polycystic ovary syndrome (PCOS) is a common endocrine disorder during a woman's reproductive period. It is estimated that 5%-10% of the women have this disease (1). Common features of PCOS include menstrual disturbance, hirsutism, acne, alopecia, obesity and infertility. Moreover, PCOS is characterized by hyperandrogenism and related to insulin resistance and other metabolic conditions (2). These clinical manifestations may affect negatively on the mental health.

In the literature, the treatment of women with PCOS is generally emphasized on the physical outcomes. PCOS is also associated with psychosocial problems, including chronic stress, depression, anxiety and decreased self-esteem, which are relevant for several reasons (3). Several studies have established that women with PCOS are more likely to experience depressive symptoms than women without PCOS (4,5,6).

Obesity is common among women with PCOS. Approximately two thirds of women with PCOS are overweight or obese, and obesity has been implicated in depression in women in the general population (7,8,9,10). Furthermore it has been shown that women with PCOS and clinical symptoms of hirsutism and acne have greater body dissatisfaction than in healthy control (5,11). Pastore et al. suggests that among non-obese PCOS women, their subjective body image was strongly associated with the severity of their depression symptoms (12).

In the current study we aimed to determine body image, self-esteem and depressive symptomatology in women with PCOS and compare with healthy controls.

Method

Setting and Sample

This study was conducted among the patients with untreated PCOS who admitted to the Outpatient Clinic of Gynecology and Obstetrics of Faculty of Medicine of Selcuk University. The exclusion criteria for the study were the following: a history or existence of bipolar disorder, schizophrenia or related disorders, a history of neurological disease and concomitant severe medical illnesses (e. g., cardiovascular or pulmonary diseases, severe renal or liver failure, any cancer) and those who were under hormone replacement or psychotropic medications within the last 4 weeks. A total of 83 consecutive women with PCOS who met the criteria of present study were included in the study. Age matched healthy controls (n=64) were recruited from employees at Selcuk University Hospital. Additional exclusion criteria for controls were any known medical condition or current psychiatric disorder, irregular periods or hormonal disturbance.

Procedures

The objectives and procedures of the study were explained and written informed consent was obtained from all participants. In addition, the study was approved by the ethical committee of Faculty of Medicine of Selcuk University. PCOS was defined according to criteria by Rotterdam ESHRE/ASRM-sponsored PCOS consensus workshop group. Women with PCOS (n=83) all met the Rotterdam criteria for PCOS (13). After recording socio-demographic characteristics of the participants in the outpatient clinic of the gynecology and obstetrics, Body Image Scale, Rosenberg Self-Esteem Scale and Beck Depression Inventory were completed by the participants.

Measures

Body Mass Index (BMI)

Body Mass Index (BMI) was calculated as the ratio of weight in kilograms to square of height in meters (kg/[m.sup.2]).

Body Image Scale (BIS)

Body Image Scale measures the satisfaction from various parts of the body. This self questionnaire was developed by Secord and Jourard in 1953 (14). This is a likert type scale and composed of 40 items. It has no cut off point. Low points indicate unsatisfaction. The Turkish version of BIS has been validated by Hovardaoglu in 1993 (15).

Rosenberg Self-Esteem Scale (RSES)

Self-esteem was measured using the Rosenberg Self-Esteem Scale (RSES) (16). The RSES is a 10-item measure of positive and negative aspects of self-esteem. The responses were scored on a 4-point Likert scale ranging from 0 (strongly agree) to 3 (strongly disagree). The overall score was computed by summing the individual items scored for minimum and maximum scores of 0 and 30, respectively. The sum of the scores was classified according to level of self-esteem, with 15-25 considered normal and scores<15 considered low self-esteem. The instrument has been extensively used in various healthy and nonhealthy populations, and its reliability and validity has been supported for measuring self-esteem (16). The Turkish version of RSES has been validated by Cuhadaroglu (17).

Beck Depression Inventory (BDI)

The severity of depressive symptoms was assessed using the Beck Depression Inventory (BDI). The Turkish version of the BDI used in this study has been validated in Turkish populations (18).

Statistical Analysis

All analyses were performed with SPSS version 15.0 for Windows. Data met the criteria for parametric analysis. The chi-square test was used to evaluate socio-demographic data (education, marital status, employment, economic status, previous psychiatric history). Independent samples't test was used to determine whether there were differences between patients and controls for age, BMI, BDI, BIS and RSES scores. Statistical significance was assumed as p<0.05.

Results

A total of 83 women with PCOS and 64 age matched healthy women were recruited.

PCOS group was compared with the control group for socio-demographic characteristics (Table 1). Patients with PCOS and healthy controls did not differ in some socio-demographic variables, including age, education and economic status (p>0.05). Being employed and being married was more prevalent among the control group. However, previous psychiatric history was more prevalent among the PCOS group (p<0.05).

The mean[+ or -]S.D. BMI of PCOS and control groups were 23.85[+ or -]4.67 kg/[m.sup.2] and 22.00[+ or -]2.43 kg/[m.sup.2], respectively. Body mass index values of the PCOS group were significantly higher than the controls (p<0.05). A clinically obese subject does not exist in both groups (BMI [less than or equal to] 25 kg/[m.sup.2])

Beck depression inventory scores were significantly higher in the PCOS group compared to the healthy controls (p<0.05). There was no significant difference between the PCOS group and healthy controls for Body Image Scale (BIS) scores and Rosenberg Self-Esteem Scale (RSES) scores (p>0.05). Body mass index, BDI, BIS and RSES scores are presented in Table 2.

Discussion

The main finding of this study is that depressive symptomatology is more prevalent among women with PCOS than healthy controls. Although women with PCOS were not obese, their BMI were greater than healthy controls in our study. Furthermore, previous psychiatric history was more prevalent among the PCOS group. However we didn't find any difference between PCOS and control groups in terms of body image and self esteem.

Our depression symptom scores support the few prior reports of a high prevalence of depression/depression symptoms in women with PCOS (5,19,20). Some authors suggest that women with hyperandrogenic syndromes may be at an increased risk for mood disorders due to an association between elevated androgen levels and depression (21,22). Rasgon et al. (21) suggest that women receiving oral contraceptives for the treatment of PCOS were less depressed than patients not receiving this type of treatment. However, we did not evaluate hormone levels of women with PCOS and healthy controls. In this study, we found previous psychiatric history was more prevalent among the PCOS group. However, we didn't conduct psychiatric clinical Interview.

Obesity is common among women with PCOS. Obesity and resistance to insulin plays a significant role in the pathogenesis of PCOS. Obesity itself increases the risk of insulin resistance, although insulin resistance can also occur in the absence of obesity in PCOS (2,23). Obesity also linked to depression (10). Furthermore, many studies have reported an association between insulin resistance and depression (24). However, we didn't analyze the relationship between insulin resistance and depression in this study.

Previous studies have noted a positive correlation between BMI and depressive symptoms in women with PCOS (19,20,25). In this study, although there was no clinically obese for PCOS group, BMI values of the PCOS group were significantly higher than the controls. All of the patients with PCOS were young and newly diagnosed for PCOS. Therefore, our patients were less exposed to hyperandrogenic effect. For this reason, our findings may be not consistent with the previous findings.

Pastore and colleagues suggest that a strong positive association between depression symptom severity and dissatisfaction with their physical appearance and physical conditioning in women with PCOS (12). Niet et al. (26) reported that women with PCOS had lower levels of self esteem, greater fear of negative appearance evaluation. In mentioned study, it was determined that clinical characteristics such as hyperandrogenism and acne were associated with poorer body satisfaction, whereas hirsutism and BMI unfavorably affect all measured psychosocial variables. However, we didn't found any differences between the BIS scores and self-esteem scores of women with PCOS and healthy controls. This reason can be explained as follows, women with PCOS who participated in this study were not obese, young and newly diagnosed for PCOS. There was no long-lasting hormonal effect in these women. We should note as a limitation that we didn't evaluate acne and hirsutism in women with PCOS. Therefore, this study couldn't reveal a connection between physical consequences such as acne and hirsutism and depressive symptomatology. The cross-sectional design restricts the interpretation of an association between depressive symptomatology and body image and self-esteem on women with PCOS in the present study. Another limitation of this study is that the newly diagnosed subject could not show that long-lasting hyperandrogenic effect in PCOS women.

In conclusion, despite several limitations, the present study suggests that PCOS seems to be associated with depressive symptomatology. Furthermore, rising BMI values of these women may be an indicator for the onset of PCOS. However, these results should be confirmed by prospective studies.

Doi: 10.4274/npa.y6778

References

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(4.) Elsenbruch S, Hahn S, Kowalsky D, Offner AH, Schedlowski M, Mann K, Janssen OE. Quality of life, psychosocial well-being, and sexual satisfaction in women with polycystic ovary syndrome. J Clin Endocrinol Metab 2003; 88:5801-5807.

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(25.) 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; 33:1132-1138.

(26.) de Niet JE, de Koning CM, Pastoor H, Duivenvoorden HJ, Valkenburg O, Ramakers MJ, Passchier J, de Klerk C, Laven JS. Psychological well-being and sexarche in women with polycystic ovary syndrome. Hum Reprod 2010; 25:1497-1503.

BILGE BURCAK ANNAGUR [1], AYBIKE TAZEGUL [2], NURSEL AKBABA [1]

[1] Selcuk University Faculty of Medicine, Department of Psychiatry, Konya, Turkey

[2] Selcuk University Faculty of Medicine Department of Medicine, Department of Obstetrics and Gynecology, Konya, \ Turkey

Correspondence Address/Yazflma Adresi

Bilge Burcak Annagur MD, Selcuk University Faculty of Medicine, Department of Psychiatry, Konya, Turkey

Gsm: +90505 790 65 53 E-mail: bilgeannagur@yahoo.com Received/Gelis tarihi: 29.07.2012 Accepted/Kabul tarihi: 14.11.2012
Table 1. Socio-demographic data of the groups

                            PCOS (n=83)      Control (n=64)
                          Mean [+ or -] SD   Mean [+ or -] SD     p

Age (mean years            22.27 [+ or -]     22.85 [+ or -]    >0.05
  [+ or -] S.D) (a)             1.84               2.06
Marital status (b)
Married (%)                   2 (2.4)           11 (17.2)       <0.001
Single (%)                   81 (97.6)          53 (82.8)       >0.05
Educationb
Elementary School(%)          1 (1.2)            1 (1.6)        >0.05
High School (%)              15 (18.1)          11 (17.2)       >0.05
University (%)               67 (80.7)          52 (81.3)       >0.05
Employment status (b)
Employed (%)                  8 (9.6)           30 (46.9)       <0.001
Unemployed (%)               75 (90.4)          34 (53.2)       >0.05
Economic statusb
Low economic status (%)        3(3.6)            7 (10.9)       >0.05
Medium economic
  status (%)                 75 (90.4)          54 (84.4)       >0.05
Good economic
  status (%)                  5 (6.0)            3 (4.7)        >0.05
Previous psychiatric
  history (b)
Present (%)                  26 (31.3)           3 (4.7)        <0.001
Absent (%)                   57 (68.7)          61 (95.3)       >0.05

(a) indicates t test

(b) indicates [chi square] test

Table 2. Body Mass Index (BMI), Beck Depression
Inventory (BDI), Body Image Scale (BIS) and Rosenberg
Self-Esteem Scale Scores (RSES) of PCOS and control
groups

                     PCOS (n=83)              Control (n=64)
                     Mean [+ or -] SD         Mean [+ or -] SD

BMI (kg/[m.sup.2])   23.85 [+ or -] 4.67    22.00 [+ or -] 2.43
BDI score            14.60 [+ or -] 8.54     6.07 [+ or -] 3.85
BIS score            97.62 [+ or -] 20.44   93.14 [+ or -] 17.13
RSES score           20.02 [+ or -] 5.48    20.39 [+ or -] 3.32

                              t                      p

BMI (kg/[m.sup.2])          3.107                  0.002
BDI score                   8.884                  <0.001
BIS score                   1.414                   0.16
RSES score                  -0.501                  0.61
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Title Annotation:Research Article/Arastirma Makalesi
Author:Annagur, Bilge Burcak; Tazegul, Aybike; Akbaba, Nursel
Publication:Archives of Neuropsychiatry
Article Type:Report
Geographic Code:7TURK
Date:Jun 1, 2014
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