Management of polycystic ovary syndrome (PCOS) in adolescents entails dealing not only with the physical manifestations but also the troubling psychosocial effects related to these physical manifestations. The author conducted a literature review to ascertain the adverse psychosocial effects of PCOS in adolescents, as well as what nurse practitioners can do to mitigate these effects.
Key words: polycystic ovary syndrome, PCOS, adolescence, psychosocial effects
Polycystic ovary syndrome (PCOS) is a common endocrine disorder that affects 5%-10% of women and typically begins during adolescence.1-5 Common physical manifestations of PCOS—acne, obesity, hirsutism, and anovulation—can have adverse effects on adolescents’ self-image and mood.6,7 As a result, many of these girls may withdraw from their peers because of emotional distress or embarrassment. In addition to lowering self-esteem, obesity and the features of metabolic syndrome can increase the risk for future health complications,8,9 which in turn can provoke anxiety in adolescents who are aware of these risks. With all of these negative forces at play, adolescents with PCOS are also at increased risk for depression.10 In this article, the author shares the results of a literature search on the psychosocial concerns related to PCOS in adolescents and what nurse practitioners can do to address these concerns.
Literature review
The author searched the PubMed, Google Scholar, CINAHL, and JSTOR databases to find articles published between 2002 and 2013 that pertained to the adverse psychosocial effects of PCOS in adolescents, including management of these effects. Key words in the search were polycystic ovarian syndrome, PCOS, adolescence, teens, quality of life,
psychosocial, psychosocial issues, depression, anxiety, eating disorders, hirsutism, obesity, and metabolic syndrome. Other articles were found by hand-searching relevant studies cited in the articles initially found.
Articles met inclusion criteria if they covered psychosocial concerns related to PCOS in adolescents. Articles describing the physical effects of PCOS were included if they served to provide relevant background information. Studies focusing only on adults were excluded unless, again, they provided useful background information or they compared PCOS-related psychosocial concerns in adolescents versus adults.
Psychosocial concerns related to PCOS
Table 1 lists selected studies related to psychosocial concerns in adolescents with PCOS. These concerns include anxiety and depression,1,4 social interaction,11,12 body image,11 body weight,1,11,13,14 eating disorders,15 hirsutism,13 fertility,2,11,13 and decreased quality of life (QOL) related to sexual behavior.2,11 Health-related QOL (HQOL) scores in adolescents have been correlated with the level of PCOS symptomatology.14 A qualitative study showed that a PCOS diagnosis had an adverse impact on HQOL, with emotional and social functioning being more affected than physical health.11
Psychological problems
According to a report by Dowdy,10 adolescents with PCOS commonly use words such as nerd or freak to describe themselves; PCOS changes their bodies, which makes them feel different from other adolescents. A small study showed that adolescents with PCOS, compared with healthy adolescents, had higher anxiety scale scores.4 Dowdy10 reported that anxiety among adolescents with PCOS was related to their appearance, body-image concerns, and fear of future infertility.
Insulin resistance and increased levels of insulin in the bloodstream, which are common in patients with PCOS, have been thought to cause problems with mood.16 Insulin levels in the blood can affect serotonin levels in the brain and vice versa, so it is unclear whether insulin abnormalities initiate depressive symptoms or are the result of them.10
Body weight and body-image disturbances
Overweight/obesity (OW/O) and an elevated body mass index (BMI) are more common in adolescents with PCOS than in those without PCOS.8,14 Excess weight, among all the physical manifestations of PCOS in adolescents, has the greatest adverse impact on HQOL.17,18 One study showed that HQOL scores were inversely proportional to BMI values in teens with PCOS and high BMIs.14 PCOS-related OW/O has been linked to decreased academic achievement and lower income, even after controlling for socioeconomic status and intelligence. In addition, many females with OW/O are the recipients of hurtful comments and actions from peers, family members, colleagues, strangers, and even some healthcare providers,19 which can lower their self-esteem.
Other body-image concerns in adolescents with PCOS involve male-pattern hair on the face and body and acne.10 Adolescents with hirsutism, versus those without the condition, have lower HQOL scores and self-esteem and an increased prevalence of anxiety disorders.20 Some adolescents report feeling that hirsutism has robbed them of their female identity.10 PCOS-related insulin resistance increases the risk for developing acanthosis nigricans (a brown to black, poorly defined, velvety hyperpigmentation of the skin),21 another body-image concern because of its physical visibility.
Femininity, fertility, and sexuality concerns
According to the dictionary, feminine means “having the qualities traditionally ascribed to women.”22 Menstruation is an important symbol of femininity; menarche and a normal menstrual cycle serve as rites of passage that prove that a female has the ability to reproduce.4 Adolescents with PCOS, versus their healthy peers, are more likely to have concerns about their future fertility because of their menstrual irregularities.2 Fear of potential infertility has an adverse impact on HQOL.
Adolescents with PCOS, compared with adolescents who do not have PCOS, may feel more self-conscious, less desirable, and less inclined to be outgoing with persons to whom they are attracted.10 A teen with PCOS may feel unsexy or unwomanly because her body has “let her down,” and she may have less sexual interest because of the many PCOS-related stressors with which she must cope.10Eating disorders
Results of a retrospective study showed that adolescents with menstrual disturbances were at greater risk of having an eating disorder.23 Adolescents with OW/O may develop unhealthy eating habits such as binge eating, purging, dieting, and using diuretics or laxatives to lose weight.24 Some adolescents with PCOS feel that their efforts to lose weight are not as successful as those of their peers who do not have PCOS.10
Screening for adverse psychosocial effects of PCOS
Screening for psychosocial concerns related to PCOS should start early in adolescence. Table 2 lists screening tests available for identification of psychosocial problems.25 An evaluation of the Polycystic Ovary Syndrome Questionnaire (PCOSQ) by Jones et al26 found this tool reliable for determining HQOL in women with PCOS. Validity of the tool could be improved with the addition of acne to the questionnaire because of acne’s identification as an important factor involved in HQOL. Although the PCOSQ was first developed based on research conducted on women,27 it has been used in adolescents to assess psychosocial concerns related to PCOS.13
NP role in managing psychosocial effects of PCOS
Goals of therapy for adolescents with PCOS—amelioration of psychological problems, weight loss, reduction of the manifestations of hyperandrogenism, and improvement in body image and self-esteem—are best achieved by a multidisciplinary team that includes NPs.3,4,28 The physical and psychosocial aspects of treatment go hand in hand. Meeting physical management goals (e.g., weight loss, reduction in hyperandrogenism manifestations) can lessen some of the troubling psychosocial effects, and enhancing self-esteem can motivate weight-loss efforts and perhaps even improve adherence to the pharmacotherapeutic regimen. One of the best ways that NPs can help is to supply adolescent patients with information about PCOS and its treatment that they can understand.
Mental health approaches
An open trial of weekly cognitive behavioral therapy sessions and family sessions has shown that these modalities may help treat both depressive symptoms and obesity in adolescents with PCOS.1 Participating in individual and family sessions can help patients develop positive methods of coping with PCOS and find constructive ways to manage their feelings. Support groups that meet in person or online can help motivate adolescents to make and maintain healthy lifestyle choices.29,30 NPs can recommend any or all of these psychotherapeutic approaches.
Lifestyle changes
Weight loss of 5%-10% may not only decrease cardiovascular risks and insulin resistance but also help improve HQOL.8,14,31 NPs should ascertain which weight-loss strategies have worked or not worked in the past, and identify any unsafe weight-loss strategies and eating patterns in which patients may be engaged.24,29 In these cases, NPs should offer patients safe alternatives for losing weight.24
A case–control study showed that, compared with controls, girls with PCOS engaged in physical activities less often (if they did exercise, they did so with less frequency and intensity), and they were less likely to be aware of the beneficial effects of exercise on their health.32 NPs should encourage patients to exercise regularly, which may help increase their self-esteem and overall health.13,19 Yoga may be even more beneficial; results of a recent randomized, controlled trial indicated that yoga effectuated a significantly greater increase in HQOL than did traditional exercise.33
With regard to approaches to counter the effects of hyperandrogenism, unwanted hair can be removed temporarily via shaving, waxing, and/or plucking (which unfortunately may cause other unwanted effects such as irritation, scarring, or folliculitis). Laser treatments can provide more permanent results, but many treatments may be needed and the treatments may be costly.34
Medications
Oral contraceptives (OCs) regulate menstrual cycles and treat hirsutism and acne.28,34 Insulin sensitizers such as metformin can be used to treat underlying insulin resistance.34,35 However, a randomized, placebo-controlled trial showed that adding metformin to a regimen of lifestyle changes and OC use did not lead to a significant improvement in HQOL.13 Anti-androgens such as spironolactone can help manage the hyperandrogenism effects.34,36 Statins are first-line treatments for lowering low-density lipoprotein cholesterol levels.37 Antidepressants and anxiolytics can be used to treat psychiatric disorders related to PCOS; in these cases, NPs may want to consult with a mental health specialist.
Further research
An important topic for future study is the efficacy of implementing a HQOL survey at every primary care visit for adolescents with PCOS. The purpose of this survey would be to assess for psychosocial co-morbidities common in individuals with PCOS. The studies should ascertain whether implementing such a screening would make providers more aware of the adverse psychosocial effects of PCOS, help identify psychosocial symptoms, and facilitate more comprehensive treatment when needed. Additional research should determine the outcomes of losing weight, how other PCOS-specific interventions affect overall HQOL, how to address infertility concerns, and how primary care practitioners can best manage adolescents holistically to help improve HQOL. More research is needed regarding how providers should teach and communicate with adolescents with PCOS.
Conclusion
Polycystic ovary syndrome in adolescents involves a myriad of physical manifestations that can compromise psychosocial health. These adverse psychosocial effects may have a major impact on HQOL. Early diagnosis of PCOS, screening for adverse psychosocial effects, and treatment that reduces physical manifestations of PCOS are important. Lack of attention to these problems can force adolescents to endure adverse psychosocial effects that can lead to further unhealthy behaviors. NPs have an opportunity to educate adolescents about the disease process of PCOS and to implement strategies to treat these patients’ physical and psychosocial problems to improve their HQOL for a lifetime.
Joyce S. Lee is a certified pediatric nurse practitioner who graduated from Columbia University School of Nursing in New York, New York. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.
Acknowledgment
The author thanks Rita Marie John, DNP, EdD, CPNP-PC, DCC, for her help, editing, and counsel during the preparation and writing of this article.
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