Psychological aspects of polycystic ovary syndrome

Introduction

Polycystic ovary syndrome (PCOS) is a complex condition that affects the endocrine, reproductive, and metabolic systems (Witchel et al. 2020; Norman et al. 2007). It is currently recognized as the most common endocrine disorder among women of reproductive age (Wolf et al. 2018; Azziz et al. 2016). PCOS is typically characterized by hyperandrogenism, irregular ovulation, and polycystic ovarian morphology (Chiaffarino et al. 2022). According to international diagnostic guidelines, a diagnosis requires the presence of at least two of these three criteria, following the exclusion of other endocrine disorders with similar features (Teede et al. 2018). Beyond its physical manifestations, PCOS is increasingly linked to a range of psychological and neurocognitive issues, including psychiatric disorders and sexual dysfunction, which are known to negatively affect quality of life (Pinto et al. 2024). Among the best-documented difficulties are disturbances in emotional functioning, with numerous epidemiological studies confirming significantly higher rates of depression and anxiety among women with PCOS compared to the general population (Alur-Gupta and Dokras 2023; Conney and Dokras 2017; Brutocao et al. 2018). These conditions are now recognized as major psychosocial burdens associated with the syndrome. Sexual dysfunctions constitute another important, though less clearly defined, area of research. Evidence suggests that women with PCOS are at increased risk of reduced sexual satisfaction and impaired functioning; however, methodological inconsistencies and the lack of standardized assessment tools limit the comparability of findings (Thannickal et al. 2020; Teede et al. 2023). Similarly, disordered eating behaviors and body image disturbances are frequently reported in both clinical and community samples but remain underexplored in systematic research despite their relevance for mental health and treatment adherence (Lee et al. 2019; Lalonde-Bester et al. 2024; Teede et al. 2023). The least investigated domain concerns cognitive functioning. Although empirical evidence is scarce, several mechanisms suggest potential impairment, including vascular risk factors associated with metabolic syndrome and the indirect effects of emotional disorders such as depression and anxiety (Pinto et al. 2024; Naz et al. 2023; Schattmann and Sherwin 2007). These pathways make cognitive dysfunction in PCOS a plausible but insufficiently studied phenomenon. Taken together, the psychological aspects of PCOS encompass both well-documented and emerging areas of research. While emotional disorders are consistently recognized, domains such as sexual functioning, disordered eating, and cognitive performance require further systematic investigation. This review seeks to integrate current findings across these domains to provide a comprehensive perspective on the psychological and neuropsychiatric aspects of PCOS, with a focus on their implications for overall well-being.

Depressive symptoms and anxiety

The incidence of depression among women with PCOS is significantly higher than in the general population (Cooney et al. 2017; Damone et al. 2019; Głowińska et al. 2016). Research indicates that women with PCOS are approximately three to five times more likely to experience depressive and anxiety symptoms, respectively (Naz et al. 2023). Cooney et al. (2017) examined the association between PCOS and depressive symptoms across more than thirty cross-sectional studies. Depression was assessed using validated tools such as the Beck Depression Inventory (BDI) and the Hospital Anxiety and Depression Scale (HADS). Their findings indicated a median prevalence of depression of 36.6% (IQR: 22.3-50.0%) in women with PCOS, compared to 14.2% (IQR: 10.7-22.2%) in the control group (without PCOS). Women with PCOS demonstrated significantly increased odds of experiencing any depressive symptoms (OR = 3.78, 95% CI: 3.03-4.72) and moderate to severe depressive symptoms (OR = 4.18, 95% CI: 2.68-6.52). Similarly, Damone et al. (2019) reported a higher prevalence of depression in women with PCOS (27.3%) compared to healthy controls (18.8%). The odds of reporting depressive symptoms or scoring in the clinical risk range for depression were 1.61 times higher in the PCOS group (95% CI: 1.29-2.03, p < 0.001). The underlying mechanisms behind the elevated risk of depression in PCOS remain unclear, though several contributing factors have been proposed. These include hyperandrogenemia, infertility, high body mass index (BMI), and insulin resistance (Naz et al. 2023; Fernandes et al. 2022; Azziz et al. 2006). Hyperandrogenism – one of the diagnostic features of PCOS – has been associated with both physical symptoms such as hirsutism and increased psychological distress. Ekback et al. (2013) found that women with pronounced hirsutism reported significantly more depressive symptoms than those with milder hair growth. Additionally, meta-analytic data indicate that women with depressive symptoms had higher mean Ferriman-Gallwey (FG) scores (SMD = 0.18, 95% CI: 0.04-0.31), which are used for the assessment and quantification of hirsutism; depression was associated with increased odds of hirsutism (OR = 1.53, 95% CI: 1.10-2.12) across six studies. Insulin resistance is another contributing factor. Fernandes et al. (2022) conducted a meta-analysis of 70 studies involving 240,704 participants and found that insulin levels and the HOMA-IR index were elevated during episodes of acute depression, particularly in individuals with atypical depression. Notably, these changes did not persist during remission, and antidepressant treatment had no significant impact on insulin resistance, suggesting a specific link between acute depressive states and metabolic dysregulation. Hormonal disturbances, particularly involving the hypothalamic-pituitary-adrenal (HPA) axis, have also been implicated in PCOS-related depression. It has been hypothesized that abnormal GnRH secretion leads to increased luteinizing hormone (LH) levels. This dysregulation may be due to increased pituitary sensitivity to GnRH or the rapid frequency of GnRH pulses, potentially driven by reduced neurotransmitter (e.g., dopamine or endorphin) inhibition of hypothalamic activity (Azziz et al. 2006; Lujan et al. 2008). Recent neurobiological research has proposed that PCOS may be associated with changes in brain structure and function linked to mood regulation. A study by Li et al. (2020) using fMRI reported altered functional connectivity in limbic-prefrontal circuits in women with PCOS, which correlated with depressive symptom severity. Moreover, reduced levels of brain-derived neurotrophic factor (BDNF) – a marker of neuronal health – have been observed in women with both PCOS and depressive symptoms, suggesting a shared neurobiological basis (Kim et al. 2021). There is growing recognition that depression may not only be a consequence of PCOS but may also exacerbate its symptoms, suggesting a bidirectional relationship. Chronic psychological stress and depressive symptoms can disrupt endocrine and metabolic homeostasis, potentially worsening insulin resistance and ovulatory dysfunction (Dubé-Zinatelli et al. 2025). Given these findings, early screening for depression in PCOS patients is essential. Integrative treatment approaches – including lifestyle interventions, psychological therapy (especially cognitive behavioral therapy), and pharmacological management – may be particularly effective in improving both mental health and metabolic outcomes (Majidzadeh et al. 2023). Meta-analyses also show a 2-fold higher risk of incidence of bipolar disorder (BIP) among women with PCOS than in the general population. Furthermore, active substances such as valproate (VPA), frequently used as a mood stabilizer in BIP, have been observed to contribute to the development and exacerbation of symptoms of this endocrinopathy. Promising research is ongoing into the genetic basis of the co-occurrence of both disorders, especially as regards the development of PCOS associated with VPA use (Jaholkowski et al. 2025).

Eating disorder

The mechanisms underlying this phenomenon include metabolic disturbances (hyperinsulinemia, insulin resistance), hormonal alterations (hyperandrogenism), and psychological factors such as body image dissatisfaction, stress, and low self-esteem (Góral et al. 2025). Insulin resistance promotes sudden hunger and carbohydrate cravings, whereas androgens may influence appetite and mood, further contributing to the development of disordered eating behaviors (Góral et al. 2025). Women PCOS demonstrate a higher prevalence of eating disorders compared to the general population. A meta-analysis by Lee et al., including eight studies, showed that the risk of abnormal screening results for eating disorders in patients with PCOS was more than three times higher, and the risk of a clinical diagnosis was nearly four times greater (OR = 3.87) (Lee et al. 2019). A systematic review by Thannickal et al. (2020), based on data from over 349,529 women, confirmed a significantly increased likelihood of bulimia nervosa (OR = 1.37) and binge eating disorder (OR = 2.95) in PCOS, with no elevated risk of anorexia nervosa. Cross-sectional studies further indicate that binge eating symptoms may affect up to 60% of obese patients with PCOS, with the strongest predictive factors being food cravings, emotional eating, and loss of control over food intake (Jeanes et al. 2017). A scoping review by Lalonde-Bester et al. (2024), summarizing 38 studies, showed that the prevalence of eating disorders among women with PCOS ranges widely from 0% to 62%, with the risk of their development being three to six times higher compared to the general population. The authors emphasized that the etiology of eating disorders in PCOS is therefore multifactorial, involving metabolic, hormonal, psychological, and neuroendocrine factors, which highlights the need for early screening and multidisciplinary management.

Body image

Women with PCOS frequently experience significant concerns related to body image, which encompass dissatisfaction with body weight, shape, and specific physical characteristics, including hirsutism, acne, and central adiposity. Alkheyr et al. (2024) conducted a cross-sectional study involving 12,199 women, of whom 3329 had PCOS, and found that women with PCOS reported markedly lower levels of body image satisfaction compared to women without the condition. The study highlighted behavioral manifestations of body image concerns: women with PCOS were more likely to avoid mirrors (61.7% vs. 49.8%) and social interactions (22.3% vs. 32.3%), reflecting heightened self-consciousness regarding appearance. Additionally, a larger proportion of women with PCOS expressed a desire to lose weight (75.2% vs. 68.5%), and increased body weight was strongly associated with perceptions of reduced attractiveness. Overall, fewer women with PCOS reported feeling confident or satisfied with their physical appearance (38.6% vs. 50.7%). Body image disturbances in PCOS are not limited to general dissatisfaction with weight or appearance but often include preoccupation with specific symptoms of the syndrome, such as hirsutism or acne, which may exacerbate self-consciousness and feelings of unattractiveness. Huangfu et al. (2024) emphasized that such preoccupations can lead to pervasive negative evaluations of the body, even when objective measures of body size or health fall within normal ranges. The 2023 International Evidence-based Guideline for the Assessment and Management of PCOS emphasizes that health professionals and patients should be aware of the potential impact of PCOS features on body image. The guideline recommends routine screening for body image concerns using a stepped or regionally adapted approach, and if negative body image is identified, appropriate interventions such as psychological therapy should be offered (Teede et al. 2023). Addressing body image disturbances in women with PCOS therefore requires targeted strategies focused on body acceptance, realistic self-perception, and coping mechanisms for appearance-related distress, rather than focusing solely on secondary psychological outcomes. These findings underscore that body image concerns in PCOS are multifaceted, encompassing cognitive, perceptual, and behavioral dimensions that significantly affect how women perceive and relate to their bodies (Sun and Yi 2024). The evidence indicates that addressing body image concerns in women with PCOS requires targeted interventions that promote body acceptance, foster realistic self-perception, and provide coping strategies for appearance-related distress, rather than focusing solely on secondary psychological outcomes (Alkheyr et al. 2024; Huangfu et al. 2024; Sun and Yi 2024). Collectively, these findings highlight negative body image as a key risk factor for psychological distress and disordered eating in women with PCOS. Consequently, a comprehensive therapeutic approach addressing both somatic and psychological dimensions – including interventions that enhance body acceptance, strengthen self-esteem, and improve stress management – is essential.

Sexual functioning

Sexual functioning represents an important, yet relatively under-researched, aspect of life in women with PCOS. Studies indicate that women with this syndrome more frequently experience reduced sexual satisfaction, difficulties with arousal and orgasm, as well as decreased libido compared to the general population. Elsenbruch et al. (2003) comparing 50 women with PCOS to 50 control women, demonstrated that PCOS is associated with significant limitations in sexual satisfaction. De Niet et al. (2010), in a study of 480 women with PCOS, found that amenorrhea correlated with lower self-esteem, higher social anxiety, and earlier sexual initiation. Similarly, Stovall et al. (2012), analyzing 92 women with PCOS and 82 control women, reported significantly lower satisfaction in terms of orgasm and sexual fulfillment in the PCOS group. De Frene et al. (2015), studying 31 couples in which the woman had PCOS and overweight, noted that women with PCOS showed a different pattern of deriving sexual and relational satisfaction compared to their partners. Significant factors contributing to sexual difficulties included both hormonal changes – particularly hyperandrogenism – and psychological factors such as depression, anxiety, and lowered self-esteem resulting from a negative body image. Additionally, overweight and obesity, which often coexist with PCOS, may exacerbate problems in sexual functioning by reducing bodily comfort and increasing feelings of unattractiveness. Despite the growing number of studies in this area, methodological limitations – such as the use of different questionnaires, lack of standardization, and small sample sizes – hinder comparison of results and the drawing of definitive conclusions. It is important to emphasize that the assessment of sexual functioning should consider not only the presence of difficulties but also their impact on distress and quality of life, in line with the diagnostic criteria for sexual disorders. Further systematic research is necessary to develop effective therapeutic interventions that address both biological and psychosocial determinants of sexual dysfunction in women with PCOS. Moreover, the 2023 International Evidence-based Guideline for the assessment and management of PCOS (ESHRE) highlights that sexual health should be routinely evaluated as part of holistic patient care, emphasizing the need for standardized assessment tools and interventions tailored to both physiological and psychosocial factors (Teede et al. 2023).

Cognitive impairments

Emerging research suggests that neurocognitive dysfunction is not confined to classical neurological or psychiatric disorders but may also be present in medical conditions with hormonal and dermatological components. For instance, Deveci et al. (2014) investigated cognitive functioning in patients with acne vulgaris – a dermatological condition associated with hyperandrogenism and psychological stress, much like PCOS. Their study demonstrated that individuals with acne performed significantly worse on neurocognitive assessments evaluating attention, working memory, and executive functions compared to healthy controls. These findings highlight the broader neurocognitive impact of endocrine and inflammatory disturbances, supporting the hypothesis that hormonal dysregulation, chronic low-grade inflammation, and psychological distress may also contribute to the cognitive difficulties frequently observed in women with PCOS. Over the past decade, accumulating evidence has revealed the adverse effects of PCOS on multiple domains of cognitive and emotional function. Cognitive abilities such as attention, reasoning, memory, executive function, and psychomotor speed appear particularly vulnerable. Several mechanisms have been proposed to explain this phenomenon. Hormonal imbalances – specifically elevated androgen levels – are commonly cited as potential contributors to cognitive dysfunction. In addition, metabolic features of PCOS, including insulin resistance, systemic inflammation, and abnormalities of the hypothalamic–pituitary–adrenal (HPA) axis, may further impair cognitive performance. Several studies directly support these associations. Schattmann and Sherwin (2007) found that women with PCOS had significantly poorer scores on cognitive tests such as the Purdue Pegboard and the Controlled Oral Word Association Test (COWAT). These deficits correlated negatively with free androgen index (FAI) levels, indicating that elevated androgens were associated with reduced verbal fluency, visuospatial working memory, and manual dexterity. Similarly, Lujan and Mergler (2015) observed diminished spatial ability and manual coordination in women with PCOS compared to healthy controls. Extending this evidence, Soleman et al. (2016) reported that women with PCOS exhibited greater activation in the superior and inferior parietal lobes during working memory tasks, suggesting altered neural recruitment patterns associated with cognitive processing. Further supporting the role of hyperandrogenism, Sukhapure et al. (2022) found that higher levels of free testosterone were significantly associated with poorer performance on the Timed Chase Test (TCT) and Groton Maze Learning Test (GMLT), particularly affecting psychomotor speed and visuospatial learning. In another cross-sectional study, Mehrabadi et al. (2020) compared 53 women with PCOS to 50 healthy controls and reported significantly lower performance in visual-spatial ability, executive function, attention, and overall cognitive function (as measured by the Montreal Cognitive Assessment [MoCA]) in the PCOS group. These findings underscore the cognitive vulnerabilities faced by women with PCOS and suggest a link between cognitive performance and the severity of clinical symptoms such as hirsutism and acne. Growing evidence also suggests that insulin resistance, a hallmark of PCOS, may contribute to cognitive dysfunction. Research from non-PCOS populations has established a connection between insulin dysregulation and impaired brain structure and function. For instance, Benedict et al. (2012) found that higher HOMA-IR scores were associated with reduced verbal fluency and decreased gray matter volume in the temporal lobe – areas critical for memory and language processing. Similarly, Kuusisto et al. (1997) showed that insulin resistance features, including hyperinsulinemia and glucose intolerance, were significantly associated with increased risk of Alzheimer’s disease, independent of the APOE ε4 genotype. These findings emphasize the potential role of metabolic dysfunction in cognitive decline and support the hypothesis that insulin resistance may be a mechanistic link between PCOS and neurocognitive impairment. Given the high prevalence of insulin resistance among women with PCOS, these associations merit further exploration in future research.

Psychotic symptoms

Increasing evidence indicates that women with PCOS are at an elevated risk of experiencing both subclinical psychotic symptoms and clinically diagnosed psychotic disorders. A large population-based longitudinal study based on the Northern Finland Birth Cohort demonstrated a significantly elevated incidence of psychotic disorders, particularly schizophrenia spectrum disorders, among women with PCOS compared with controls, and this association persisted after adjustment for body mass index, metabolic factors, and familial liability to psychosis (Karjula et al. 2022). These findings suggest that the observed risk cannot be fully explained by obesity- or lifestyle-related factors alone. A narrative review published in Frontiers in Psychiatry (Doretto et al. 2020) further contextualized this association by highlighting shared neuroendocrine and metabolic mechanisms linking PCOS and psychosis, including dysregulation of the hypothalamic–pituitary–gonadal axis, hyperandrogenism, relative progesterone deficiency, and instability of estrogen signaling. Given the proposed neuroprotective and antidopaminergic effects of estrogens, their dysregulation in PCOS may contribute to increased vulnerability to psychotic symptoms. Additionally, the authors emphasized the role of insulin resistance, chronic low-grade inflammation, and oxidative stress as overlapping biological pathways implicated in both PCOS and psychotic disorders. More recently, a Mendelian randomization study provided genetic evidence for a potential bidirectional relationship. It demonstrated that genetic liability to schizophrenia may increase the risk of PCOS. Thereby it supported the hypothesis of shared genetic and neurobiological susceptibility rather than a purely psychosocial explanation for the association (Wen et al. 2026). Collectively, these findings underscore the importance of recognizing psychotic symptoms as a clinically relevant, though underappreciated, aspect of the psychological burden associated with PCOS. These studies highlight the need for early recognition of PCOS in psychiatric patients, comprehensive metabolic and hormonal monitoring, and integrated care between psychiatry and gynecology.

Conclusions

In summary, PCOS is a multifaceted disorder that extends beyond reproductive and metabolic abnormalities to encompass significant psychological and cognitive impairments. The elevated prevalence of depression, anxiety, and cognitive deficits observed in women with PCOS appears to arise from a complex interplay of hormonal imbalances, insulin resistance, chronic inflammation, and neuroendocrine dysregulation. These neuropsychiatric manifestations not only adversely affect patients’ quality of life but may also exacerbate the somatic symptoms of PCOS, thereby establishing a detrimental feedback loop. Neuroimaging and biomarker studies provide robust evidence of structural and functional brain alterations associated with mood and cognitive disturbances in this population (Ozgen Saydam and Yildiz 2021). Consequently, comprehensive clinical management of PCOS necessitates routine psychological and cognitive evaluations. Multimodal therapeutic strategies – integrating hormonal regulation, insulin-sensitizing agents, mental health interventions, and lifestyle modifications – are imperative to optimize both psychological and somatic outcomes. Future investigations should focus on identifying the underlying causal mechanisms and improving therapeutic approaches to reduce the neurocognitive and emotional challenges experienced by women with PCOS. Epidemiological findings underscore the necessity for further rigorous investigations into the pathogenetic mechanisms underlying these associations. Importantly, future research should adopt a lifespan perspective to examine the development and progression of PCOS-related psychological, cognitive, and somatic symptoms across different stages of a woman’s life, thereby identifying critical periods for intervention and long-term management. Studies should include not only healthy control groups but also clinical comparative cohorts (differentiated in terms of symptom severity, and also including groups of women in adolescence, perimenopause, and postmenopause) to better elucidate syndrome-specific effects. Another critical challenge is the standardization of research tools, including ensuring availability of different language versions and widespread use in international studies, to enhance comparability and reproducibility of findings. It is important to emphasize that the comparability of research results is limited due to the lack of standardized diagnostic tools. Different studies often use various questionnaires to assess the same psychological domain, which makes cross-country and cross-study comparisons difficult. This methodological inconsistency represents a significant challenge for meta-analyses and systematic reviews in the field. Moreover, systematic screening for depression, anxiety, and cognitive impairment among women with PCOS is warranted, with prompt initiation of appropriate therapeutic measures as indicated. This review underscores the importance of incorporating assessment of the aforementioned psychological aspects in the routine evaluation of newly diagnosed PCOS patients to ensure comprehensive and effective care.

Disclosures

This research received no external funding.
The study was approved by the Bioethics Committee of the Poznan University of Medical Sciences (Approval No. 742/20).
The authors declare no conflict of interest.

References