1 Introduction
Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders in reproductive-aged women. Depending on the diagnostic criteria used, the prevalence of PCOS varies from 6 to 18 % [
1‐
6]. Prevalence also varies according to ethnicity [
7,
8] and PCOS is also associated with factors such as body weight and lifestyle [
9]. The Rotterdam criteria, which are now the internationally accepted diagnostic criteria for PCOS, require any two of the following three criteria: oligo- or anovulation, clinical and/or biochemical hyperandrogenism, and polycystic ovaries [
10]. This can result in a variety of reproductive PCOS phenotypes. The reproductive features of PCOS include being the leading cause of anovulatory infertility among reproductive-aged women [
6,
11]. PCOS is underpinned by insulin resistance and is associated with comorbidities including hypertension, dyslipidemia, obesity, and increased risk of metabolic syndrome and type 2 diabetes mellitus [
12‐
15].
PCOS can also have a significant negative impact on women’s health-related quality of life (HRQoL) [
16‐
18] and psychological function [
19]. It has been reported that women with PCOS have higher levels of depression than other women [
20], a finding replicated in a variety of populations [
16,
19,
21]. Likewise, women with PCOS typically report higher levels of anxiety compared with healthy women [
19,
20,
22]. High anxiety levels have also been reported in adolescent girls with PCOS [
23]. A meta-analysis by Barry et al. [
24] highlighted that psychological distress is experienced by women affected by PCOS. Compared with women with other chronic conditions, including diabetes, back pain, and arthritis, women with PCOS have been shown to have similar or better physical HRQoL, but poorer psychological HRQoL [
25]. Poorer HRQoL for women with PCOS has been well established and a specific questionnaire has been developed to assess this construct in relation to the specific phenotypes of PCOS (PCOS-Q [
26]). It has been suggested that the symptoms of PCOS may reduce psychological wellbeing [
27] as many of the associated features of PCOS (obesity [
28], infertility [
29], hirsutism [
30], and hormone imbalance [
31]) are independently associated with poorer mental health.
In an otherwise healthy population, lifestyle modifications, in particular physical activity, are prescribed to optimize mental health conditions [
32], and high levels of physical activity are associated with higher HRQoL and general vitality [
33]. These improvements are also observed in people with chronic health conditions [
34]. There is emerging evidence to suggest that many of the pathophysiological symptoms of PCOS can be improved by regular participation in physical activity [
35,
36]. Quality of life and mental health may improve for women via the positive effects of physical activity on symptomology and comorbidity severity and/or occurrence [
35]. For example, in obese populations, physical activity-induced weight reduction has been associated with improvements in depressive symptoms [
36]. However, the evidence surrounding the effects of physical activity participation on mental health and HRQoL for women with PCOS is limited. Therefore, our aim is to review the available literature concerning mental health and physical activity for women with PCOS.
2 Literature Search
The researchers accessed PubMed and EBSCO Research electronic databases between November and December of 2013 and searched for relevant studies between January 1970 and December 2013. The search terms included ‘polycystic ovarian syndrome’, ‘Stein-Leventhal syndrome’, ‘PCOS’, ‘exercise’, ‘physical activity’, ‘mental health’, ‘depression’, ‘anxiety’, ‘health related quality of life’, and ‘HRQoL’. Only papers written in English were considered for this review. To be included in the review, the research needed to include women with PCOS, have a focus on mental health or quality of life outcomes and prescribe or measure physical activity.
3 Findings
Our search found 73 articles, but only seven papers considered mental health outcomes and implemented exercise interventions in women with PCOS (Table
1). No criteria was placed on study design; however, all studies identified reported randomized designs. To our knowledge, there is only one randomized controlled trial (RCT) with the principal aim of assessing the impact of lifestyle modification on depressive symptoms and HRQoL in women with PCOS and this study was actually a subset from a larger study [
37]. In this RCT, researchers compared three different 20-week lifestyle programs for 49 overweight/obese patients: diet only, diet and aerobic exercise, or diet and combined aerobic–resistance exercise. All groups achieved similar amounts of weight loss and had similar improvements in depression and all domains of PCOS-specific HRQoL, aside from the body hair domain. However, there was no comparison of an exercise intervention with standard care or a control.
Table 1
Outcomes of studies assessing the influence of exercise on mental health for women with PCOS
Lifestyle interventions: diet and exercise
| |
| RCT | 28 | Overweight females with PCOS HPLC: age 33.0 ± 1.2 years BMI 37.6 ± 6.4 kg/m2
LPHC: age 32.0 ± 1.2 years BMI 37.2 ± 6.9 kg/m2
| HADS Rosenberg Self Esteem Rating Scale | 12 weeks | Two energy-restricted diets (6,000 kJ/day) + one exercise training per week (brisk walking and aerobic and stretching exercises) 4 weeks maintenance diet HPLC diet: n = 14, DO: 2 LPHC diet: n = 14, DO: 1 | Depressive symptoms decreased (p < 0.01) and self-esteem increased (p < 0.05) in HPLC group. No significant change in anxiety in either group |
| RCT | 94 | Obese females with PCOS (relatively high depressive symptoms and impaired HRQoL) Age 29.3 ± 0.7 years BMI 36.1 ± 0.5 kg/m2
| CES-D PCOSQ | 20 weeks | Diet and aerobic exercise (n = 31, DO: 16), 5/week walking/jogging Diet and combined aerobic–resistance exercise (n = 33, DO: 13): 3/week walking/jogging + 2/week strength training Diet (n = 30, DO: 16): 6,000 kJ/day energy-restricted high-protein meal plan | All groups improved in all PCOS-specific HRQoL scores, except for body hair domain score. Clinically significant improvements in emotion, body weight and menstrual problems (d > 0.5) |
Exercise and medicine
| |
Harris-Glocker et al. [ 43] | RCT | 36 | Obese, adolescent females with PCOS Age range: 12–18 years BMI 34.8 kg/m2
| PCOSQ | 6 months | MET group: Oral contraceptive with metformin + motivation + diet + exercise (weekly, 60-min group exercise) PBO group: Placebo + motivation + diet + exercise (weekly, 60-min group exercise) | PCOSQ total scores significantly improved in both groups, across all domains, between baseline and conclusion. No significant difference between the groups |
| RCT | 22 | Obese, adolescent females with PCOS MET group: age 16.1 ± 1.5 years BMI 37.1 ± 5.8 kg/m2
PBO group: age 15.4 ± 1.2 years BMI 35.9 ± 6.6 kg/m2
| PCOSQ | 6 months | MET group (n = 11, DO: 1): metformin + 150 min/week of exercise + low-calorie diet PBO group (n = 11, DO: 3): placebo + 150 min/week of exercise + low-calorie diet | Improvements in overall quality of life in both groups (data not reported) |
| RCT | 114 | Obese females with PCOS MET group: age 29.0 ± 4.5 years BMI 38.0 ± 7.8 kg/m2
PBO group: age 28.8 ± 4.6 years BMI 38.3 ± 8.0 kg/m2
| PCOSQ | 6 months | MET group (n = 55, DO: 33): metformin + low-calorie diet + 150 min/week of exercise PBO group (n = 59, DO: 43): placebo + low-calorie diet + 150 min/week of exercise | Non-significant improvements in domains of quality of life (weight and emotion only) for both groups |
Other interventions
| |
| RCT | 90 | Healthy adolescent females with PCOS Exercise: age 16.2 ± 0.9 years BMI 21.2 ± 3.0 kg/m2
Yoga: age 16.2 ± 1.1 years BMI 20.3 ± 1.9 kg/m2
| STAI | 12 weeks | Typical exercise (n = 45, DO: 10): 1 h/day Traditional yoga (n = 45, DO: 8): 1 h/day | Both groups significantly decreased state and trait anxiety over the intervention. Yoga group decreased trait anxiety more than exercise group |
Stener-Victorin et al. [ 38] | RCT | 72 | Females with PCOS Age 29.9 ± 4.4 years BMI = 28.1 ± 7.4 kg/m2
| BSA-S MADRS PCOSQ SF-36 | 16 weeks | Exercise (n = 29): 3/week for 16 weeks, self-selected, more than 30 min Acupuncture (n = 28): 2/week for 2 weeks + 1/week for 14 weeks Controls (n = 15): oral information about exercise, no intervention | Exercise: Role physical significantly decreased, Emotions and infertility (PCOSQ) significantly increased Acupuncture: Role physical, social function, energy/vitality, general health perception, mental component, emotions (PCOSQ) significantly increased Controls: Emotions, weight, menstruation (PCOSQ) significantly increased Between-group change: Acupuncture significantly increased role physical |
The other studies compared exercise with different forms of treatment. Stener-Victorin et al. [
38] compared an acupuncture group, a control group, and an exercise group and found that all interventions increased HRQoL to a similar degree. However, there was a modest improvement in depression and anxiety score in women treated with acupuncture, compared with typical exercise and with the control group. In another study comparing a traditional exercise program with yoga among a group of adolescents [
39], state and trait anxiety decreased following both interventions. The remaining research included intervention studies with exercise included as a part of a multi-factor lifestyle modification. Similar to the study by Thomson et al. [
37], it is difficult to isolate the independent contribution of physical activity to the overall change observed in HRQoL, depression, and anxiety. Specifically, Galletly et al. [
40] prescribed exercise in addition to different diets, while in Ladson et al. [
41,
42] and Harris-Glocker et al. [
43] trials exercise was complemented by metformin prescription. There was no additional benefit when exercise was combined with diet or medication (metformin) and as there was no standard care/control groups, the independent effect of the exercise in the interventions is difficult to assess.
Six of the seven research studies which have evaluated mental health and quality of life in the context of physical activity have reported positive mental health outcomes. However, the studies included in the review vary greatly in sample size and population, study design, measurement tools, concurrent therapies, and comparison group. Given this, it is difficult to draw firm conclusions about the effects of physical activity alone on the mental health outcomes of women with PCOS. The evidence supporting the association between PCOS and poorer mental health is very strong [
16,
19], as is the association between PCOS and low physical activity levels [
44]. Exercise is commonly advised as a positive lifestyle therapy for optimizing mental health in otherwise healthy populations [
45]. However, there is limited evidence to support claims that exercise is a suitable therapy for optimizing mental health in women with PCOS. Most studies found physical activity was associated with a beneficial effect on mental health for women with PCOS. Ladson et al. [
42] were the only researchers to find no significant changes on overall quality of life following an exercise program, a result that may be explained by the high levels of drop-out from the study.
5 Conclusions
Despite a sound rationale for exercise and physical activity to improve mental health in PCOS, there is limited evidence documenting the specific effects of physical activity on mental health for women with PCOS. However, the existing research does suggest that physical activity is a positive intervention for both physical and mental health for these women, with no results indicating an adverse impact. Previous research clearly indicates that women with PCOS are more likely to report higher levels of depression and anxiety and lower levels of HRQoL. More studies are now needed to understand the mechanisms underlying the relationship between mental health and physical activity for women with PCOS. There is also a need to better design studies, to use consistent measurement tools to compare different types of physical activity, intensity, and frequency of physical activity in women with PCOS in order to improve health-related outcomes including fitness, well-being, and quality of life and to inform clinical recommendations regarding the prescription of physical activity for these women.
Acknowledgments
This was a researcher-instigated review and no funding was received to assist in the preparation of this review.
A/Prof Stepto is supported by the Australian Government Collaborative Research Network scheme. Prof Teede is an NHMRC Practitioner Fellow.
The authors report no conflict of interest.
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