Polycystic ovary syndrome associated with development of postpartum depression: AJOG study
Polycystic ovary syndrome (PCOS) is the most common endocrine metabolic disorder in women of reproductive age worldwide. PCOS is characterized by anovulation, hyperandrogenism, and polycystic ovarian morphology, with a prevalence ranging between 4% and 12% in the United States.
Women with PCOS are more likely to experience several pregnancy complications including hypertensive disorders, gestational diabetes, and preterm births and are substantially more likely to experience infertility and seek related treatment than those without the syndrome. In addition, existing research has demonstrated that nonpregnant women with PCOS have increased susceptibility to depression (28%-64%) and anxiety (34%-57%), namely, infertile women.
A study was carried by Koric A, Singh B, VanDerslice JA et al. with a primary objective to assess the association between a prepregnancy diagnosis and symptoms of PCOS and prevalence of depression and anxiety during pregnancy and in the postpartum period among a population-based sample. The secondary objective was to assess whether prenatal depression, anxiety, and pregnancy complications mediate the association between PCOS and PPD.
The study involved a population-based sample of 3906 postpartum (2-6 months) women who completed the Utah Pregnancy Risk Assessment Monitoring System Phase 8 questionnaire (2016-2018). Weighted adjusted prevalence ratios were used to assess the association between polycystic ovary syndrome and postpartum depression, considering potential confounding factors and assessing mediating effects of depression and anxiety experienced during pregnancy.
The presence of PCOS before pregnancy was assessed based on clinical PCOS and common symptoms. A PCOS symptomology question asked, "Have you ever experienced any of the following health problems?"—with the following choices: (1) "Irregular periods (menstruation)"; (2) "Skin condition that causes pimples (acne)"; (3) "Increased hair growth on the face, chest, or other parts of the body (hirsutism)"; and (4) "Being overweight or obese." PCOS symptomology was defined in possible alternate ways as having (1) irregular periods and acne, (2) irregular periods and hirsutism, or (3) irregular periods, acne, and hirsutism.
To assess the presence of prenatal or pregnancy depression and anxiety, women were asked, "During your most recent pregnancy, did you have any of the following health conditions?"—where depression and anxiety were listed as possible choices, with responses "yes or no." PPD was defined having answered "always" or "often" to either of the following 2 questions that captured PPD or a postpartum depressed mood (1) and anhedonia (2): (1) "Since your new baby was born, how often have you felt down, depressed, or hopeless?" and (2) "Since your new baby was born, how often have you had little interest or little pleasure in doing things you usually enjoyed?"
- In weighted analyses, of the 3906 women, 8.2% of women were diagnosed as having PCOS. Those with clinical PCOS were older, had higher BMI, and were more likely to report prenatal depression, prenatal anxiety, and postpartum depressed mood or anhedonia than those without the syndrome. Similarly, women with clinical PCOS were more likely to report irregular periods and acne, irregular periods and hirsutism, and irregular periods, acne, and hirsutism.
- Following the exclusion criteria, 8.2% of women reported clinical polycystic ovary syndrome and 19.1%, 6.2%, and 4.4% reported irregular periods and acne, irregular periods and hirsutism, and all 3 symptoms, respectively.
- 17.7% and 23.5% reported experiencing prenatal depression and anxiety and 9.5% and 10.2% reported experiencing postpartum depressed mood and anhedonia, respectively.
- Clinical polycystic ovary syndrome was associated with a 1.76 higher adjusted prevalence ratio for postpartum depressed mood or anhedonia after taking into consideration age, prepregnancy body mass index, race/ethnicity, education, and marital status.
- A similar higher prevalence was seen for irregular periods and acne (adjusted prevalence ratio, 1.65; 95% confidence interval), irregular periods and hirsutism (adjusted prevalence ratio, 1.40; 95% confidence interval), and all 3 symptoms (adjusted prevalence ratio, 1.75; 95% confidence interval) and postpartum depressed mood or anhedonia.
- Prenatal depression and anxiety mediated 20% and 32% of the effect of clinical polycystic ovary syndrome on postpartum depressed mood and anhedonia, respectively.
Clinical studies have shown that women with PCOS have increased susceptibility to depression and anxiety and postpartum depressed mood potentially owing to hormonal imbalance and distressed metabolic profiles such as elevated androgens, hypersensitivity of the hypothalamic pituitary-adrenal axis, and greater plasma adrenocorticotropic hormone and serum cortisol levels. These conditions make women with PCOS less resilient compared with women without PCOS to similar stressful events caused by pregnancy, infertility treatment, and pregnancy-related complications.
These findings show that PCOS is associated with postpartum depressive mood or anhedonia among a population-based sample, targeted specifically at high-risk mothers. In addition, the findings indicate that preconception and prenatal depression and anxiety, but not pregnancy complications including GDM and HDP, mediate the association between PCOS and postpartum depressed mood. This emphasizes the value of prenatal psychological screening among women with clinical PCOS because symptoms associated with the syndrome are known to contribute to poor mental health and in turn are likely to elevate the risk of depression and anxiety. An additional important clinical and public health implication of this study lies in the finding that nearly 20% of women in this population-based sample who reported at least 2 PCOS symptoms (including at risk women who may not have access to care) had not received a clinical diagnosis for PCOS.
"Future studies with detailed medical records data will be needed to confirm PCOS diagnosis and therefore confirm our findings. Nevertheless, our findings highlight the importance of assessing for PCOS symptoms in addition to clinical diagnosis in nationally representative population-based surveys such as PRAMS."
Source: Koric A, Singh B, VanDerslice JA, et al. Polycystic ovary syndrome and postpartum depression symptoms: a population-based cohort study. Am J Obstet Gynecol 2021;224:591.e1-12.