Differential Contributions of Polycystic Ovary Syndrome (PCOS) Manifestations to Psychological Symptoms Judy G. McCook, PhD, RN Beth A. Bailey, PhD Stacey L. Williams, PhD Sheeba Anand, MD, MPH Nancy E. Reame, PhD, FAAN Abstract The purpose of this study was to investigate the relative contributions of previously identified Polycystic ovary syndrome (PCOS) manifestations (infertility, hirsutism, obesity, menstrual problems) to multiple psychological symptoms. Participants were 126 female endocrinology patient volunteers diagnosed with PCOS who completed a cross-sectional study of PCOS manifestations and psychological symptoms. Participants had significantly elevated scores on nine subscales of psychological symptoms. Menstrual problems were significantly associated with all symptom subscales as well as the global indicator, while hirsutism and obesity were significantly related to five or more subscales. After controlling for demographic factors, menstrual problems were the strongest predictor of psychological symptoms. Findings suggest features of excess body hair, obesity, and menstrual abnormalities carry unique risks for adverse psychologic symptoms, but menstrual problems may be the most salient of these features and deserve particular attention as a marker for psychological risk among women with PCOS.

Introduction Polycystic ovary syndrome (PCOS) is characterized as a spectrum of clinical manifestations such as menstrual irregularity, infertility, markers of hyperandrogenism (e.g., hirsutism), and obesity.1,2 According to the Third PCOS Consensus Workshop Group (CWG) in 2012, the prevalence of

Address correspondence to Judy G. McCook, PhD, RN, College of Nursing, East Tennessee State University, P.O. Box 70676, Johnson City, TN 37614, USA. Phone: +1-423-4394061; Email: [email protected]. Beth A. Bailey, PhD, Department of Family Medicine, East Tennessee State University, Johnson City, TN, USA. Stacey L. Williams, PhD, Department of Psychology, East Tennessee State University, Johnson City, TN, USA. Sheeba Anand, MD, MPH, Internal Medicine Residency Program, East Tennessee State University, Johnson City, TN, USA. Nancy E. Reame, PhD, FAAN, School of Nursing, Columbia University, New York, NY, USA.

)

Journal of Behavioral Health Services & Research, 2014. 1–12. c 2014 National Council for Behavioral Health.

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PCOS in developed countries ranges from 6–15%, with exact prevalence depending on specific PCOS criteria used.3 The 2010 U.S. census reported 112,806,642 women aged 18–44 years.4 This suggests that between 6 million and 17 million women in the U.S. during prime childbearing years are affected by PCOS. In addition to the obvious negative health-related impact of PCOS, this prevalence of PCOS may be additionally concerning due to its potential psychological impact. A growing body of work has demonstrated a link between PCOS and psychological symptoms. Severe mental health issues including anxiety, depression, body dissatisfaction, and eating disorders, decreased sexual satisfaction, and decreased health-related quality of life were reviewed by Himelein and Thatcher, in an extensive mental health literature examination of women with PCOS.5 Elsenbruch et al. reported women with PCOS had significantly greater obsessive–compulsive, interpersonal sensitivity, depression, aggression, and psychoticism scores when compared with healthy agematched women. Because scores on two global indices of the tool used (SCL-90-R) were also elevated compared with age-matched healthy women, the investigators concluded that women with PCOS are at greater risk in general for psychological morbidity.6 Although evidence is accumulating that psychological morbidity is higher among women with PCOS than healthy controls, the specific PCOS-related manifestations most predictive of psychological symptoms are less definitive. Because excess facial or body hair in women is perceived as socially undesirable, hirsutism or male pattern facial and body hair distribution may be one of the most distressing symptoms among women who have PCOS.7–9 Based on in-depth interviews of 30 U.S. women with PCOS, Kitzinger and Willmott concluded that these women are “challenged in their perceptions of themselves as feminine and as women.”10 In other studies, hirsutism has been associated with anxiety,9 depression,11 social phobia and psychotic symptoms,9 and somatization.12,13 Yet hirsutism alone may not account for the entire negative mood in PCOS women.14 In prior research, hirsutism was ranked as having the least impact on quality of life of five factors examined among women with PCOS.15 Excess body weight has also been widely reported as a key concern to women with PCOS.6,11–13,15,16 Indeed, obesity is believed to contribute substantially to negative psychological symptoms in women with PCOS.17 Hollinrake and colleagues found significantly increased depression among PCOS participants as compared with healthy controls and revealed that, among women with PCOS, those who were depressed presented with a significantly higher Body Mass Index than those not depressed.18 Similar to conclusions about hirsutism, some have suggested obesity is a complex manifestation and not the only factor contributing to depression in women with PCOS.6,18 Another hallmark of PCOS is infertility, which may also lead to psychological symptoms. Some studies have shown a relationship between infertility and negative psychological symptoms in women with PCOS.6 In addition, “wishing to conceive” has been related to decreased quality of life.12 However, findings on the impact of infertility on psychological well-being have been inconsistent. For example, a study by Tan et al. showed no significant differences in subscales of the SCL-90, which measures dimensions psychological distress, between women with a current unfulfilled wish to conceive a child and those without.12 Similar findings were reported by Hahn et al.19 Inconsistent reports may be due in part to the differing ways infertility can be defined (e.g., unfulfilled wish to conceive, reproductive loss versus live birth outcome). Finally, menstrual irregularities such as anovulation, amenorrhea, and oligomenorrhea are common experiences among women with PCOS but have not been consistently examined against psychological symptoms. Some researchers argue that sociocultural factors and social pressures may lead some women to perceive menstrual problems and infertility as more problematic than other features of PCOS. 20 Semi-structured interviews with women with PCOS revealed that many believe they are abnormal or not real women due to the fact that they cannot predict when they will menstruate.21 Such questioning of normality may be reflective of distress and translate into

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psychological symptoms. However, Hahn et al. found no significant differences in psychological distress by type of menstrual problems (e.g., amenorrhea versus oligomenorrhea).19 The research presented above provides insight into women’s experiences with PCOS. However, most do not tell us which manifestations of PCOS are most salient in the experience of psychological distress, nor do they examine the full range of psychological symptoms that women might encounter in their lives.22–24 One exception includes a German study by Hahn et al., who studied a number of PCOS symptoms as predictors of quality of life, sexual satisfaction, and psychosocial wellbeing in 120 women with PCOS (and a small comparison group of 50 healthy women).19 Their results indicated that BMI and hirsutism predicted quality of life and sexual satisfaction, but no significant associations of androgens or insulin resistance, or menstrual disturbances or infertility, with psychological outcomes were indicated. This study needs validation in other samples, especially in light of the recent conclusions and recommendations of the Third PCOS CWG. In particular, the group concluded there is evidence of increased prevalence of psychological disorders in women with PCOS, but that it is unclear if this is due to the disorder itself or its manifestations (i.e., obesity, hirsutism, irregular menses, infertility). Consequently, they indicated that future research needs to determine the prevalence of specific psychological problems using well-validated instruments, and needs to examine whether its manifestations, and which ones specifically, lead to psychological disorders. Thus, the present paper draws on the conclusions and focuses on the knowledge gaps identified by the Third CWG. It is also based on previous work showing the importance of four specific PCOS manifestations on quality of life,15 and on the recent work by Hahn et al. in a German sample.19 By focusing on obesity, menstrual irregularity, infertility, and hirsutism, the link between specific PCOS manifestations and psychological symptoms can be validated and will allow for the determination of the relative importance of particular PCOS manifestations for psychological morbidity, all which could have implications for health care professionals caring for women with PCOS. Thus, the primary goal of the current investigation was to examine the associations between hirsutism, obesity, menstrual problems and infertility, and dimensions of psychological symptoms. Specifically, we were interested in the relative contribution of each of the four PCOS manifestations in predicting the separate psychological symptoms (nine dimensions of the BSI), controlling for important background characteristics.

Materials and Methods Design overview After IRB approval by the participating universities, participants were recruited from patients with PCOS at a private reproductive endocrine/infertility practice with sites in two cities in two different states in southern Appalachia. Women who had been previously diagnosed with PCOS and were scheduled for a routine follow-up appointment were invited to participate. A selfadministered health survey containing eight questionnaires was completed during the early follicular phase of the participant’s menstrual cycle. Results from two separate instruments, the Brief Symptom Inventory25 and the Health-Related Quality of Life Questionnaire for Women with PCOS,26 as well as demographic data, reproductive history, and health-related portions of the survey, were analyzed in the current study. Sample To participate, volunteers had to be at least 18 years old; be able to read, write, and understand English; and have no chronic condition other than PCOS. As previously described,15 a diagnosis of PCOS was made by the presence of two of the three primary criteria as specified in the Revised

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2003 Rotterdam ESHRE/ASRM Criteria.2 In addition, participants were excluded for pregnancy, lactation, and abnormally elevated thyroid stimulation hormone, prolactin, and/or FSH values. All hormonal evaluations were performed in the early follicular phase, approximately 3–5 days after the first day of menses. Participants with estradiol values above the normal range for this phase of the cycle (950 pg/ml) were also excluded. Based on these selection and exclusion criteria, 126 of the 158 women who completed the study survey were included in data analysis.

Procedure After the study was explained to potential participants and written consent was obtained, fasting venous blood samples were drawn. Participants then completed the health survey while waiting for scheduled appointments with the reproductive endocrine specialist and/or nutritionist.

Measures Women were asked to self-report basic demographic factors including age, race, marital status, education level, employment status, household income, and fertility status. Body Mass Index (BMI=weight/height squared [kilograms per square meter]) was determined for all participants. In addition, clinical assessment of hirsutism use the Ferriman-Gallwey Scoring (F/G score) System.27 Nine body sites are graded from 0 through 4, with 0=no terminal hair, to 4=severe hirsutism. Scores can range from 0 to 36. The normal F/G score for women is zero. A score between 1 and 7 is considered abnormal female body hair growth, and a score of 8 or above is considered positive for hirsutism.28 Finally, whether or not a diagnosis of infertility (12 months of unprotected sexual intercourse without conception) has been made was also recorded for each woman. The completed health survey contained two tools of interest to the current study: the Brief Symptom Inventory (BSI) and the Health-Related Quality of Life Questionnaire for Women with PCOS (PCOSQ). The BSI, a brief form of the SCL-90-R, is a 53-item self-report symptom inventory designed to reflect psychological symptom patterns.25 Each item is rated on a five-point scale of distress (0–4), from “not at all” to “extremely.” The BSI is scored for a global index and nine primary symptom dimensions (somatization, obsessive–compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism). The PCOSQ26 contains 26 items rated on a seven-point scale, in which minimal to no problems in each area are represented by a 7, and a score of 1 indicates the greatest level of problems. For ease of interpretation in the current investigation, scales were reverse scored so that higher scores represented more problems in that dimension. Of interest to the current investigation were three of the five scales: Infertility, Body Hair, and Menstrual Problems. The Infertility Scale is comprised of three items that ask about specific concerns in the previous 2 weeks (how often are you concerned about fertility problems, how often have you been afraid you will not be able to have children, and how often have you been sad because of infertility problems). The Body Hair Scale contains five items about frequency of concerns in the previous 2 weeks (problem with growth of visible hair on upper lip, visible hair on chin, visible hair on face, visible body hair in general, and embarrassment about excessive body hair). The Menstrual Problems Scale also contains four items that ask about concerns during the last menstruation (irregular menstrual periods, abdominal bloating, cramps, and headaches). More recently, and based on item and scale analysis, a fifth item originally part of the Emotions Scale (late menstrual period) has also been included as part of the Menstrual Problems Scale, as done here.29 Total scores on each scale are normed by dividing by the number of items, with the total score ranging from 1 to 7. Previous work with this scale revealed high associations between these self-report dimensions and more objective clinical indicators of these features, suggesting that both can be used to represent the specific manifestations of PCOS.15

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Data coding and analysis All variables of interest were checked for normality of distribution prior to analysis, and no violations were noted. Descriptive analyses were performed to provide a summary of the characteristics of the study participants. The four primary predictors (i.e., PCOS-related manifestations) of interest were represented by six different variables. Obesity was determined by an objective five-level BMI score [≤18.5 (Underweight), 18.5–24.9 (Normal weight), 25.0–29.9 (Overweight), 30.0–44.9 (Obese), ≥45(Morbidly obese)], which was treated as continuous. Infertility status was represented by an objective measure (previous diagnosis of infertility based on medical criteria), while scores on the PCOSQ Infertility Scale represented infertility concerns. Hirsutism was represented by two different variables: an objective marker (F/G Score) and the PCOSQ Body Hair Scale. Finally, severity of Menstrual Problems was indicated by scores on the PCOSQ Menstrual Problems Scale, which asked specifically about irregular, late, and heavy periods. Biochemical verification of anovulation was not utilized in the current study as a marker of menstrual problems due to potential significant overlap with infertility status. The nine BSI dimension scores, as well as the total Global Severity Index, were used to represent psychological symptoms. Since the sample did not contain a control group of women without PCOS, current participants were compared with norming samples on the BSI to examine the relative level of distress in the sample. Two norming samples (adult non-patient females and adult female psychiatric outpatients) were used.25 The sample of non-patients contained 480 women similar to the current sample in that they were mostly Caucasian (86%) and mostly married (60%); however, the norming sample was slightly older (mean age, 46 years) than the current participants. The sample of female psychiatric inpatients (n=577), while more comparable in age (mean age, 31 years), was less likely to be married (32%) and less likely to be Caucasian (67%). The current sample was compared with these two norming samples on the BSI dimension scores and global severity index using ttests. In order to answer the primary questions of interest, Pearson correlations were computed to examine the bivariate associations among the PCOS features and between each PCOS feature and each BSI dimension score. Multiple regression analysis was used to examine the relative power of each PCOS feature to predict psychological distress after controlling for significant background factors. Four primary demographic variables (age, education level, marital status, employment status) were significantly associated (pG0.10) with one or more of the BSI dimensions and were controlled for in the regression analysis. Because the sample was almost exclusively White, race was not controlled. Household income was also not included in the model due to missing data from six participants and significant collinearity with education level. Demographic factors were entered as a set on the first step, while the PCOS features significant in bivariate analyses competed for entry in subsequent steps, in order to determine which feature was most highly predictive of each dimension of distress. Separate regression analyses were performed, one for each BSI scale as the dependent variable.

Results Demographic and clinical characteristics of the 126 participating women are presented in Table 1. As shown, women varied widely in age and education level, with the average participant over 30 years old and with over 5 years of education beyond high school. The vast majority of women were White, married, and employed full time. The majority of participants exhibited the typical features of PCOS. Nearly three-fourths (74%) of the women were obese or morbidly obese, while less than one third (31%) had had at least one successful pregnancy. With respect to body hair, just 9% of the women had an F/G score of 0, while 60% had a score of 8 or more. Finally, menstrual problem scores from the PCOSQ ranged

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Table 1 Characteristics of study participants

Age (years) Education (years) Marital status (% married) Employment status (% full time) Annual household income (%≥$40,000) Race (% White)

Mean (SD) or percentage

Range

30.3 (5.3) 17.1 (4.0) 78.6% 79.7% 58.7% 97.6%

18–48 11–25 G$20,000–$100,000+

N=126

from 1.0 to 6.8, with 53% of the scores above the scale midpoint. Correlations among the PCOS features ranged from 0.03 (F/G score and infertility concerns; p90.05) to 0.35 (menstrual problems and body hair scores on the PCOSQ; pG0.01). The multiple indicators of body hair had overlap but were not completely redundant, correlating 0.66 (pG0.001). Overall, the women in the sample had fairly high levels of psychological distress. Using data from the norming samples, compared with general population adult females,25 women from the current sample had significantly higher scores (pG0.001) on all nine BSI dimensions and on the global severity index (t values range from 8.1 for paranoid ideation to 16.4 for depression). In fact, women in the current sample had mean scores on five of the dimensions (somatization, obsessive– compulsive, interpersonal sensitivity, depression, and hostility) that were not significantly different (p90.05) from those of the norming sample of female psychiatric outpatients.25 Associations between PCOS-related manifestations and the various dimensions of psychological distress are presented in Table 2. As can be seen, higher levels of both obesity and body hair problems were associated with greater psychological problems in five of the dimensions, with body hair issues also relating significantly to higher Global Severity Index scores. Menstrual problems were significantly associated with all ten psychological symptom parameters (global index, nine subscale scores), while neither indicator of infertility problems was significantly associated with any of the BSI scores. Three of the psychological dimensions, somatization, depression, and psychoticism, were significantly predicted by three of the four PCOS-related manifestations (obesity, body hair, menstrual problems). Table 3 presents the results of the multiple regression analyses. After controlling for demographic factors, none of the PCOS-related manifestations remained significantly associated with scores for either obsessive–compulsive or phobic anxiety symptoms. For the remaining BSI scales, after controlling for demographics, only menstrual problems accounted for a significant amount of additional variance (ranging from 3.1% to 11.5%). However, for all of the scales, obesity or body hair issues (or both) remained significant predictors after control for demographics, but due to moderate correlations with menstrual problems (r=0.16 and 0.35, respectively) these factors did not account for a significant amount of additional unique variance in the BSI scales.

Discussion The women in the current sample, all of whom had PCOS, experienced significantly elevated levels of psychological symptoms in all dimensions assessed when compared with normative samples. In particular, these women reported problems related to somatization, obsessive–

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Table 2 Bivariate associations between features of PCOS and psychological symptoms

Psychological symptomsa Somatization Obsessive– compulsive Interpersonal sensitivity Depression Anxiety Hostility Phobic anxiety Paranoid ideation Psychoticism Global severity index

Obesity

Infertility

Infertility

Body hair

Body Mass Index

Ever had live birth

PCOSQb

FerrimanGallwey

Body hair PCOSQb

0.194* 0.014

−0.081 0.100

0.068 0.098

0.222* 0.072

0.238** 0.178

0.299*** 0.207*

0.091

0.058

0.112

0.172

0.205*

0.284**

0.186* 0.077 0.201* 0.206*

−0.063 −0.021 −0.014 −0.008

0.014 0.031 −0.063 0.038

0.189* 0.224* 0.072 0.098

0.222* 0.319*** 0.159 0.173

0.292*** 0.369*** 0.218* 0.189*

0.104

−0.009

0.040

0.104

0.167

−0.235*

0.198* 0.132

−0.056 −0.016

0.083 0.069

0.153 0.190*

0.232* 0.282**

−0.268** 0.351***

Menstrual problems PCOSQb

Cell values represent Pearson correlations or r-point biserial values *pG0.05; **pG0.01; ***pG0.001 a From the Brief Symptom Inventory(25) b Scale from the Health-Related Quality of Life Questionnaire for women with polycystic ovary syndrome

compulsiveness, interpersonal sensitivity, hostility, and especially depression. These findings confirm those of earlier studies,6,18 and reinforce the view that an adverse psychological profile may be common in women with the classic manifestations of PCOS. Results further indicate that specific manifestations of PCOS relate individually to psychological symptoms. That all of the BSI scales were associated with at least one manifestation of PCOS suggests that PCOS may have farreaching consequences for emotional well-being. This is consistent with the conclusions of a detailed literature review,30 and extends this work by characterizing the nature of nine different dimensions of psychological distress in the same sample of women. While PCOS-related manifestations were related to all dimensions of psychological symptoms, the strongest relations were found for anxiety, depression, somatization, and interpersonal sensitivity, suggesting these may be the most salient psychological symptoms women with PCOS experience. This study sought to extend prior research by determining the relative influence of four manifestations of PCOS on a host of negative psychological symptoms. Thus, another important finding of the current study is that manifestations of PCOS appear differentially associated with specific psychological symptoms. While body hair and menstrual problems most strongly predicted anxiety, obesity was most strongly associated with hostility. These patterns of associations deserve further study to more clearly elucidate their etiology. For instance, it may be that insulin levels influence obesity as well as levels of hostility, thereby explaining the link between PCOS obesity and psychological outcomes.31 Or, taking a more psychological perspective, it may be that the

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Table 3 Regression results predicting BSI scales Scale predictors

R

R2 change

F change

P value

2.30 9.00

0.063 0.003

1.81

0.132

3.00 7.52

0.022 0.007

4.37 7.97

0.003 0.006

1.90 15.33

0.116 G0.001

3.35 3.96

0.012 0.049

5.07

0.001

3.94 4.59

0.005 0.034

3.88 6.52

0.005 0.012

4.77 13.28

0.001 G0.001

a

Somatization Demographics 0.278 0.077 Menstrual problems 0.384 0.070 Obsessive–compulsive Demographics 0.247 0.061 No significant PCOS symptoms after entry of demographics Interpersonal sensitivitya Demographics 0.314 0.098 Menstrual problems 0.396 0.058 Depressionb Demographics 0.370 0.137 Menstrual problems 0.443 0.059 Anxietya Demographics 0.254 0.065 Menstrual problems 0.424 0.115 Hostilitya Demographics 0.327 0.107 Menstrual problems 0.371 0.031 Phobic anxiety Demographics 0.391 0.153 No significant PCOS symptoms after entry of demographics Paranoid ideation Demographics 0.351 0.123 Menstrual problems 0.398 0.035 Psychoticismc Demographics 0.352 0.124 Menstrual problems 0.416 0.049 Global Severity Indexb Demographics 0.384 0.148 Menstrual problems 0.490 0.093

Demographics (age, education, marital status, employment status) were entered on the first step. Subsequent steps were forward entry of significant PCOS features a All other PCOS symptoms that were significant at a bivariate level remained significantly associated with this BSI scale after control for demographics. However, after entry of Menstrual Problems, these symptoms were no longer significant b With the exception of the Ferriman-Gallwey score indicator of body hair, all other PCOS symptoms that were significant at a bivariate level remained significantly associated with this BSI scale after control for demographics. However, after entry of Menstrual Problems, these symptoms were no longer significant c With the exception of Body Mass Index, all other PCOS symptoms that were significant at a bivariate level remained significantly associated with this BSI scale after control for demographics. However, after entry of Menstrual Problems, these symptoms were no longer significant

societal expectations for women’s physicality—smooth skin and a lean body for instance—leads women with PCOS to feel anxious about their excess body hair and to feel anger about excess weight and societal negativity toward weight.

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Further examination of the relative impact of PCOS-related manifestations on dimensions of psychological distress in the current sample yielded some surprising findings. Contrary to earlier reports that PCOS-related obesity played a major role in depressive symptoms and that hirsutism was a strong predictor of psychological outcomes,5,6,9,32 the most salient emotional issue for the women in the current sample were problems related to the menstrual cycle. In the present study, menstrual problems predicted every dimension of psychological distress more strongly than any other feature of PCOS. Why menstrual problems was the strongest predictor of psychological distress in the current sample is unclear. Some of the menstrual items asked women to report experiences with late or irregular periods. Perhaps absence of a cycle without a confirmed pregnancy served as a monthly reminder for women of failed fertility, or led to concern about other potential abnormalities such as early menopause or signs of cancer. Clearly, additional research is needed to further confirm this finding, and to explore mechanisms by which this relationship may occur. Also, somewhat surprising, our results did not show a significant relation between either indicator of infertility and any of the psychological symptoms in the current sample. These findings are in contrast to some of the PCOS literature, which suggests that infertility stemming from PCOS can be a primary source of psychological distress.6,19,33–42 It may be that the make-up of our sample differed from those of prior research. For example, one third of the women had had a successful pregnancy, unlike some research involving PCOS in which most or all women in the sample had been unable to conceive and carry a pregnancy to term. Thus, perhaps fertility issues were less of a problem for the women in our sample than in other samples. The findings of the current investigation should also be considered in the context of study limitations. The lack of a non-PCOS control group clearly limits our ability to draw definitive conclusions about the elevated levels of psychological distress in women with PCOS. Future studies should include healthy volunteers and patient comparison groups matched on body weight and demographics to confirm the suggestions made here about PCOS and levels of psychological symptoms. Yet we did compare sample women to the normed values of the BSI available for both healthy women and a clinical sample of women, and current findings lend support to the expectation that our sample of women with PCOS would have higher levels of psychological symptoms than healthy women. A second limitation of this study was the relatively small, homogeneous clinical sample, assessed cross-sectionally. While the sample size and make-up, as well as the study design, are typical for studies of PCOS, the high percentage of women who are married may have biased our sample in favor of those with lower levels of depression and anxiety, as relationship status is known to affect psychological functioning. In addition, recruitment from a clinic may have biased our sample in favor of those who are already help seeking and who are financially able to afford treatment for PCOS, and women might have sought treatment because they were experiencing distress due to their PCOS symptoms. For these reasons, this field of research would greatly benefit from larger-scale longitudinal studies with more diverse samples. Only one study has examined PCOS manifestations in a large community-based sample,43 and broke new ground by designing a retrospective birth cohort study affording understanding of exact prevalence rates of PCOS in the community. However, similar work has yet to be done that incorporates psychological profiles of women. Such a study would allow for an examination of possible risk or protective factors, which could better inform treatment of psychological distress in women with PCOS. Additionally, sample diversity would allow for variation in women’s experience by characteristics like level of socioeconomic status and cultural background. Finally, associations found cross-sectionally in the current and prior studies could be examined over time to clarify whether distress stems directly from PCOS manifestations or whether pre-existing distress magnifies the perception of PCOSrelated manifestations, as well as the mediating factors that explain links between these and psychological symptoms. Thus, future longitudinal examination may further serve to confirm or

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clarify the relations between more subjective experiences and psychological outcomes found in the present study, and potentially examine a causal link. Menstrual problems and body hair often are assessed more subjectively by the woman’s reports of her personal experience as opposed to other manifestations such as weight and infertility, which also can be observed. In the present study, we used solely the PCOSQ to measure menstrual concerns. This scale does not objectively assess “late” or “irregular,” or the specific level of discomfort related to bloating, cramps, or headaches, but instead asks how frequently these problems have been a concern over the previous 2 weeks. A more objective assessment of these menstrual problems may reduce the strength of the associations between menstrual problems and psychological symptoms observed in the current study. However, most research assessing menstrual problems relies on self-report of these issues. It should also be noted that, in the case where both a PCOSQ scale and a more objective marker were available for body hair, associations for body hair were only slightly stronger for the PCOSQ variable.

Implications for Behavioral Health Despite these limitations, these findings may have implications for behavioral health research and practice. The current study adds to the existing literature by discerning the relative contributions of previously identified salient PCOS-related manifestations to adverse psychologic symptoms in a clinic sample. Findings suggest that women with PCOS who struggle with excess body hair, obesity, and menstrual abnormalities are at specific risk for depression, anxiety, somatization, and interpersonal sensitivity. Additionally, while menstrual problems and hirsutism were most predictive of women’s anxiety, obesity was most strongly related to hostility among women. Moreover, menstrual problems emerged as the most salient manifestation with psychological symptoms. Thus, knowing women’s PCOS-related manifestations may provide insight into what types of psychological symptoms they may be experiencing. Clinician awareness and treatment of specific PCOS manifestations, such as significant menstrual problems, may then point them to assess and address women’s psychological symptoms. Future longitudinal and translational research should test all of these possible implications in clinical and non-clinical samples.

Acknowledgments We are especially grateful for the women who served as research participants. This work is dedicated to the memory of the late Dr. Sam Thatcher, a generous friend, dedicated clinician, and selfless mentor. Partial funding was received for Dr. McCook from the National Institutes of Health Contraception and Infertility Loan Repayment Program. Conflict of Interest Statement The authors declare no conflict of interest, financial or otherwise.

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2014