Polycystic Ovary Syndrome (PCOS) and Sexual Dysfunctions

Abstract

Abstract

Objectives: Polycystic ovary syndrome (PCOS) is a very common endocrine disorder affecting 5% to 10% of women in reproductive age all over the world. Many comorbidities have been associated with PCOS including infertility, obesity, depression, anxiety, hirsutism, alopecia, and sexu al dysfunctions. In this paper, we have reviewed the available Indian and international literature regarding psychiatric and sexual comorbidities of PCOS.

Methods: PubMed, Cochrane, Google Scholar, and other databases were used to conduct the search. Research published in English was included. We searched the databases using the terms ‘polycystic ovary syndrome’, ‘PCOS’, ‘infertility and PCOS’, ‘sexual dysfunctions and PCOS’, etc.

Results: For this review, we could find about 90 papers pertaining to the subject. Most of them focused on the effect of infertility and symptoms of PCOS such as hirsutism on body image and sexual dysfunctions. Meta-analyses showed that women with PCOS had poor rates of sexual desire, orgasm, and lubrication. Body image often had a negative impact on sexual thoughts and fantasies.

Conclusion: Focus on sexual dysfunctions in PCOS has been emphasized only recently after high rates of its prevalence have been found. Hence, management of PCOS involves a multidisciplinary approach where proper assessment and management of sexual dysfunctions should be given its due importance.

Introduction

Polycystic ovary syndrome (PCOS) was first reported by Stein and Leventhal in 1935. It is one of the most common endocrine disorders in reproductive age, affecting 5% to 10% of women worldwide. ¹ A great concern is the high prevalence of up to 35% reported for the Indian women. ²

The 2003 Rotterdam Consensus Workshop stated that PCOS is a syndrome of ovarian dysfunction along with cardinal features of hyperandrogenism and polycystic ovary (PCO) morphology. Using the Rotterdam criteria, two of the three criteria are sufficient to diagnose PCOS:

Oligo-ovulation or anovulation

Clinical and/or biochemical signs of hyperandrogenism

Polycystic ovaries ³

It is a diagnosis of exclusion and other causes of hyperandrogenism such as thyroid disease, hyperprolactinemia, and non-classical congenital adrenal hyperplasia must be excluded. By considering hyperandrogenism as the cardinal feature, the AE-PCOS society criteria modified the diagnosis of PCOS after excluding other endocrinopathies. ⁴

Pathogenesis of PCOS

PCOS is a multifactorial disease. The susceptible genes are involved in the various steps of steroidogenesis and androgenic pathways. Also, the environment plays a vital role in the expression of these genes and in the development and progression of the disease. The popular hypothesis is that individuals with a susceptible genetic predisposition when exposed to environmental factors express the features of PCOS. Most common environmental factors include obesity and insulin resistance (IR). Some hypotheses also include fetal in-utero androgen exposure.

PCOS is currently regarded to be a multisystem metabolic reproductive disorder that has developed over decades and is expected to be further defined over the coming years. The symptoms of PCOS vary with age, race, weight, and medications, which further adds to the challenge of an accurate diagnosis. Hyperandrogenism and irregular menstruation are the cardinal features. Hyperandrogenism may manifest in the form of hirsutism, acne, and alopecia. IR manifests in the form of acanthosis nigricans. Ovaries of these women are polycystic and have a specific anatomical appearance on ultrasound imaging. These morphological changes might be seen even in patients without any clinical manifestations. Obesity, IR, and dyslipidemia are the associated metabolic dysfunctions. The abnormality in hypothalamo–pituitary-ovarian–adrenal function is the underlying mechanism responsible for this altered metabolic physiology.

Achard and Thiers described the association between a disorder of carbohydrate metabolism and hyperandrogenism in 1921 and this was called “the diabetes of bearded women.” ⁵

Various comorbidities known to be related to PCOS include infertility, obesity, impaired glucose tolerance, and type 2 diabetes mellitus (DM-2), metabolic syndrome, depression, obstructive sleep apnea (OSA), cardiovascular risk, and endometrial cancer. There are multiple screening procedures for each of these pathologies; however, the clinician must positively enquire about these conditions and have a high degree of suspicion if any manifestation is seen in PCOS patients.

Psychological Factors Associated with PCOS

As already mentioned, PCOS has a myriad of clinical symptoms including obesity, hirsutism, acne, male pattern baldness, and infertility. These have been implicated in affecting the mental health of women afflicted with PCOS. Depression is one of the most common psychiatric comorbidities associated with PCOS. Prevalence of depression in PCOS has been found to be ranging from 23% to 64% ^6-9 from studies across the world. Other studies from India have similar rates of prevalence.^{10, 11} Anxiety disorders in PCOS have been estimated to be in the range of 11.5% to 38.6%.^{6, 9, 11-13} Other disorders commonly diagnosed in PCOS include eating disorders, ¹⁴ sleep disturbances, ¹⁵ bipolar disorder, ¹⁶ sexual dysfunctions, and psychological factors like low self-esteem and body image issues. ¹⁷ With regards to bipolar disorder, one word of mention is needed for the use of valproate which has been implicated as one of the causative factors for PCOS. ¹⁸ Use of valproate should be kept in mind while evaluating PCOS in women with bipolar disorder and epilepsy.

Sexual Dysfunctions and PCOS

Sexual functioning and response in women is a complicated psychobiosocial phenomenon and is affected by multiple factors. In women with PCOS, the factors affecting sexual functioning include infertility, deranged hormone levels especially androgens, obesity, and associated problems like metabolic syndrome, body image issues, and low self-esteem. ¹⁹ Clinical interventions for the treatment of PCOS such as hormonal drugs may also have an effect on sexual functioning. These will be dealt in detail in the following sections.

1. Infertility

In the Indian subcontinent, sexual functioning and sexual intercourse are most often concerned with procreation. Many couples often shy away from sexual intercourse once their family is complete. The prevalence of infertility in women with PCOS often ranges from 70% to 80%. ²⁰ In these couples, if pregnancy does not occur within a stipulated time, sexual desire is often reduced. Pressure from relatives and society about childbearing has a profound effect on the cognition of women as women are most often blamed for infertility in the couple. Sexual intercourse then becomes a duty and a burden leading to negative cognitive thoughts and appraisal in these women which affects sexual response. Infertility can also affect the relationship between the partners in either a positive or a negative way. The relationship between infertility and sexual dysfunction is often bidirectional and it is difficult to ascertain which had appeared first. ²¹

2. Deranged Androgen Levels

One of the cardinal features of PCOS is hyperandrogenism. Elevated luteinizing hormone level leads to increased synthesis of androgens. Increased circulating androgen levels leads to a variety of virilizing changes that include clitoromegaly, hirsutism, acne, alopecia, etc. ²² These have an effect on sexual functioning. Elevated testosterone levels themselves directly have an effect on sexual motivation, desire, and response by having action both centrally in hypothalamus and peripherally on the reproductive system. ²³ However, the exact relationship between androgen levels and sexual functioning is still controversial. Few studies reported that hyperandrogenism has a negative effect on sexual functioning because of the virilizing manifestations leading to poor self-image.^24-26 Another study however pointed out the effect of testosterone in increasing sexual desire and frequency. ²⁷ Few studies however reported an equivocal effect of androgen levels on sexual functioning.^28-30 It is possible that the reason for these variable effects could be a third factor that influences both hormone levels and sexuality.

3. Obesity and Associated Factors

IR is a frequent finding in PCOS. It is independent of obesity but eventually aggravated by it. It has been found more frequently in women with PCOS and obesity when compared to PCOS women without obesity. Impaired glucose tolerance is also more common in obese individuals than otherwise. One aspect to wonder is whether obesity causes PCOS or if it is vice versa. ³¹ Women with obesity often have a multitude of reproductive problems including menstrual irregularities. In a study from Spain, prevalence of PCOS was found to be 28.3% in obese women as compared to general population (5.5%). This finding was independent of the severity of obesity and the presence of metabolic syndrome. ³² Increased testosterone levels leads to distribution of body fat in the upper region of the body in women with PCOS. This pattern of body fat distribution is seen in men and has been implicated in the causation of cardiovascular diseases such as hypertension, atherosclerosis and diabetes. Thus, there is a bidirectional relationship between PCOS and obesity and its associated symptoms such as IR, impaired glucose tolerance, and metabolic syndrome. Obesity leads to sexual inhibition, decreased sexual desire, and poor body image and low self- esteem which themselves have an effect on sexual functioning. ²⁴

4. Issues Related to Body Image and Self-esteem

Manifestations in virilization in women with PCOS include menstrual irregularities, infertility, hirsutism, acne, alopecia, seborrhea, and android pattern of obesity. All these have a deteriorating effect on the perceived body image of the woman. There is a perceived loss of “feminine identity” and this disparity between the societal ideal of the feminine body image and the change in outward appearance of a woman with PCOS leads to a significant impact in the cognition, attitude, and quality of life. ¹⁹ In a study done in Iran, women with PCOS had poorer body image satisfaction with hirsutism, higher body mass index, menstrual irregularities, and infertility as attributing factors. ³³ This may often lead to occurrence of depression and anxiety in these women. Research shows that these issues may have a role in decreased sexual desire, sexual satisfaction, and frequency of intercourse.

Studies done to assess prevalence of sexual dysfunctions in PCOS have shown rates ranging from 27.2% to 62.5%.^34-36 Studies done on sexual functioning in women with PCOS have shown that sexual dysfunctions are often seen independent of the above factors. One cross-sectional study from Iran that recruited 130 women showed that women with PCOS had decreased sexual desire and arousal, especially in the presence of higher body mass index and hirsutism. ³⁵ Another study done in Malaysia showed that the domains of arousal and lubrication were most affected in women with PCOS. ³⁶ Both these studies used female sexual function index (FSFI) to assess for sexual dysfunctions. Meta-analyses done in this area shows that women with PCOS had lower rates of sexual desire, poorer lubrication, and difficulties in orgasm. Sexual satisfaction was also found to be lower in women with PCOS as compared to controls. They also had fewer sexual thoughts and fantasies. Physical body attributes lead to negative body image and decreased self-perceived attractiveness. Dyspareunia was however found to be equivocal in both cases and controls.^{19, 24}

Management

Diagnosis of PCOS can be established by history, physical examination, and laboratory investigations, without the use of imaging modalities such as ultrasonography. Hyperandrogenism may be clinically diagnosed by the presence of excessive acne, androgenic alopecia, or hirsutism; or chemically, with high serum concentrations of total or free testosterone or dehydroepiandrosterone sulfate. ³⁷ Ovulatory dysfunction usually manifests in the form of oligomenorrhea (cycles length of more than 35 days less than 6 months) or amenorrhea (absence of menstruation for at least 3 months after a cyclic pattern has been established). ³⁸ Clinical hyperandrogenism is diagnosed by presence of hirsutism (modified Ferriman-Gallwey score > 8), acne, and baldness. A polycystic ovary is described as an ovary having 12 or more follicles (or having ≥ 25 follicles when an 8 Hz transvaginal probe is used) with a diameter of 2 to 9 mm or with ovarian volume of greater than 10 mL. ³⁹ For the diagnosis of PCOS, a single ovary meeting either or both of these definitions is sufficient.

International evidence-based guidelines for assessment and management of PCOS 2018, ESHRE have emphasized on screening and assessment for psychosexual dysfunction in women with PCOS. Assessment can be done using scales like FSFI. ⁴⁰

Management of PCOS includes use of oral contraceptives for the regulation of menstrual cycles. Diet management, use of metformin, and exercise regimens are often useful to reduce obesity and also to regularize menstrual cycles. Hirsutism is management by removal of hair using laser or electrolysis. Infertility can be managed by use of assisted reproductive therapies. ⁴¹

Management of psychological factors often requires using pharmacotherapy for the treatment of psychiatric comorbidities such as depression and anxiety. Psychotherapy methods like cognitive behavioral therapy can address poor body image and low self-esteem issues. Sexual dysfunctions can be addressed through psychotherapy, sensate focus therapy, and dual sex therapy amongst others.

Conclusion

Sexual dysfunctions are highly prevalent in PCOS. Management often needs positive screening and assessment of the same. This needs a multidisciplinary approach with a team consisting of gynecologists, infertility specialists, psychiatrists, clinical psychologists, general physicians, and endocrinologists. Prompt diagnosis and management leads to higher patient satisfaction and decreased health-care cost.