Borderline personality disorder and polycystic ovary syndrome

To the Editor

Polycystic ovary syndrome (PCOS) is diagnosed when any two of the following are present: oligo-ovulation, hyperandrogenism or polycystic ovaries on ultrasound. It affects 12–18% of Australian women of reproductive age. The pathogenesis of PCOS is unclear, but is contributed to multiple genetic and environmental factors such as obesity. PCOS has been associated with personality disorders, with PCOS sufferers noted to have chronic emotional stress and dissatisfaction, to avoid interpersonal relations and to be frustrated and afraid of intimate relationships (Scaruffi et al., 2014).

Further research has suggested a correlation between PCOS and borderline personality disorder (BPD). Roepke et al. (2010) found that 30.4% of patients with BPD had PCO compared to 6.9% in healthy controls. Another study demonstrated that oestrogen and progesterone exerted significant effects on several BPD symptoms, especially feelings of social rejection, negative and positive urgency, anger rumination and lack of premeditation (Eisenlohr-Moul et al., 2015).

Emma is a 22-year-old woman with a history of sexual abuse by her stepfather from age 10 years until she ran away from home at age 15 years. Since then, Emma had multiple psychiatric hospitalisations for suicide attempts, ongoing self-harm (lacerating her arms and legs), rapid mood swings, very poor self-esteem, episodic outbursts of rage and poor concentration. She has a diagnosis of ‘BPD’. Emma weighs 105 kg, is 162 cm in height, has hirsutism and severe acne. She described her mood and self-harm worse premenstrually. Emma had been treated with many combinations of antipsychotics, mood stabilisers and antidepressants. Currently, she is taking lamotrigine (350 mg/day), sertraline (150 mg/day) and quetiapine XR (400 mg/day). She had completed a dialectical behaviour therapy (DBT) programme in the past month – with little improvement. We diagnosed PCOS in Emma, with raised serum testosterone, lowered sex hormone–binding globulin and low oestradiol. She also had a fasting blood glucose suggesting pre-diabetes.

Emma received PCOS treatment of metformin (1000 mg twice daily [BD]), transdermal oestradiol (100 µg patch) and cyclical progesterone. She described great improvements in her mood and self-harming thoughts and behaviours.

The case above and recent work indicate that ovarian hormones might have significant effects on psychological functioning of women with BPD. Additional work is needed to ascertain whether there exists a causal relationship between altered hypothalamic–pituitary–gonadal (HPG) axis hormone levels and BPD.