Reproductive conditions are associated with mental health issues across the lifespan.

As an increasing number of women present with reproductive conditions, it is now more necessary than ever to consider multidisciplinary care that not only involves managing physical symptoms but also the screening and treatment of mental health issues.

Reproductive conditions such as polycystic ovary syndrome (PCOS), gestational diabetes (GDM), premature menopause (PM) and infertility (all causes) impact on a significant proportion of the female population.  Many of these conditions are linked to rising obesity rates and increasing maternal age. Importantly, they are also risk factors for depression and anxiety, while depression and anxiety are in turn, risk factors for lifestyle related diseases such as type 2 diabetes (DM2) and cardiovascular disease (CVD).

The following provides an illustration of the impact of some reproductive conditions on women’s mental health and wellbeing. 

Polycystic ovary syndrome

PCOS is the most common endocrine disorder in women of reproductive age, affecting 12 to 18 per cent of such women¹. Physical symptoms include acne, excess facial and body hair, obesity and menstrual irregularity. PCOS is also the most common cause of anovulatory infertility ^2-3. Prevalence of depression in women with PCOS is higher (28 to 64 per cent) and more severe^4-6 than for women in the general population (7.1 to 8 per cent) ^7-8. Prevalence of anxiety in women with PCOS ranges from 34% ⁹ to 57% ⁶, yet again, higher and more severe than for women in the general population (18%) ⁷. Hormonal, metabolic and reproductive features of PCOS such as increased obesity and infertility are likely to impact on mental health and quality of life (QOL). 

Gestational diabetes (GDM)

Prevalence of GDM (currently 5 to 10 per cent of Australian women) is increasing in the setting of rising obesity rates, older maternal age at conception and an increasing prevalence of DM2 in the community ¹⁰. GDM has a significant impact on both child and mother antenatally and postnatally with women more worried about their own and child’s health 3-5 years post delivery compared to controls ^11-12. Health problems in pregnancy including the risk of preterm delivery increases the risk of depression and also negatively impacts on QOL.¹³ Diabetes also interacts with cognition and mood influencing psychological functioning¹⁴ in a bi-directional relationship. Awareness of, and treatment of poorer mental health in women with GDM (and DM2) is important. Treating GDM with both lifestyle advice and insulin therapy results in a reduction in anxiety and depression scores and improved quality of life.¹¹ 

Premature Menopause

Up to 8 per cent of women will experience menopause before the age of 40 years.¹⁵ High levels of depression, anxiety, stress, low self esteem and low life satisfaction are found in women who have a premature menopause, particularly surgically induced.^16-17 Experiencing an event such as menopause outside the normal life stage is likely to be distressing. The reason for the premature menopause, a woman’s interpersonal situation such as whether she is in a relationship, whether she has children already, her support networks and lifestyle are all likely to impact on the experience. Targeting women with premature menopause specifically for intervention of psychological dysfunction^18-19 should be considered. If fertility issues are relevant, counselling regarding fertility options at the earliest possible time is recommended.

Infertility

Infertility in Australia is estimated to be at 7 per cent²⁰. Not only does infertility negatively affect mental health ^{6, 21-22}, but treatments associated with infertility also impact. Negative pregnancy tests following invitro fertilisation (or other assisted reproductive technology techniques) result in high anxiety and depression scores.²³  Depression has been found to be associated with low oocyte numbers and high anxiety on pick up days is also associated with lower pregnancy rates ²⁴. It should also be remembered that male partners in a couple with fertility problems are more prone to depression ²⁵ and the impact on relationships likely causes further stress and distress. The call for health practitioners to be aware of the impact on mental health in women (and their partners) who experience infertility is strong.

Mental health key points

• Routinely consider and screen for anxiety and depression in women with reproductive conditions including PCOS, GDM, premature menopause and infertility. If depression and or anxiety is suspected discuss treatment options at the earliest opportunity
• Provide access to treatment for mental health concerns
• Consider a Mental Health Plan or Care Plan for women (and male partners where relevant) with reproductive conditions and compromised psychological function
• Discuss and optimise fertility early in the treatment process for PCOS, premature menopause and infertility (other causes)
• Provide information and/or access to resources on the diagnosed reproductive condition (including treatment options) and fertility options (where appropriate)

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References:

1. March, W.A., et al., The prevalence of polycystic ovary syndrome in a community sample assessed under contrasting diagnostic criteria. Hum Reprod. 25(2): p. 544-51.

2. Brassard M, AinMelk Y, Baillargeon J. Basic infertility including polycystic ovary syndrome. Med Clin North Am 2008;92:116-92.

3. Hamilton-Fairley D, Taylor A. ABC of subfertility: annovulation. BMJ 2003;327:546-9.

4. Bhattacharya, S.M. and A. Jha, Prevalence and risk of depressive disorders in women with polycystic ovary syndrome (PCOS). Fertil Steril, 2009.

5. Laggari, V., et al., Anxiety and depression in adolescents with polycystic ovary syndrome and Mayer-Rokitansky-Kuster-Hauser syndrome. J Psychosom Obstet Gynaecol, 2009. 30(2): p. 83-8.

6. Deeks, A.A., M.E. Gibson-Helm, and H.J. Teede, Anxiety and depression in polycystic ovary syndrome: a comprehensive investigation. Fertil Steril, 2010;93 (7):2421-2423.

7. ABS, ABS National survey of mental health wellbeing: Summary of results 4326.0 www.ausstats.abs.gov.au/ausstats/subscriber.nsf/0/6AE6DA447F8985FC2CA2574EA00122BD6/$File/43260_2007.pdf, 2007.

8. Gwynn, R.C., et al., Prevalence, diagnosis, and treatment of depression and generalized anxiety disorder in a diverse urban community. Psychiatr Serv, 2008. 59(6): p. 641-7.

9. Benson, S., et al., Prevalence and implications of anxiety in polycystic ovary syndrome: results of an internet-based survey in Germany. Hum Reprod, 2009. 24(6): p. 1446-51.

10. Ross, G. Gestational diabetes. Australian Family Physician, 2006;35(6),392-6.

11. Crowther, C.A., et al (2005). Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med, 2005;352(24):2477-86.

12. Feig D., Chen E., & Naylor D. Self perceived health status of women three to five years after the diagnosis of gestational diabetes: A survey of cases and matched controls. Am J Obstet Gynecol, 1998;178(2):386-93.

13. Mautner E, Greimel E, Trutnovsky G, Daghofer F, Egger J, Lang U. Quality of life outcomes in pregnancy and postpartum complicated by hypertensive disorders, gestational diabetes and preterm birth.  J Psychosom Obstet Gynaecol, 2009. 30(4):231-237.

14. Brands, A., et al. A detailed profile of cognitive dysfunction and its relation to psychological distress in patients with type 2 diabetes mellitus. J Int Neuropsychol Soc, 2007;13(2),288-97.

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16. Liao K, Wood N, Conway G.  Premature menopause and psychological well-being. J Psychosom Obstet Gynaecol, 2000;21(3):167-174

17. Taylor, M.Psychological consequences of surgical menopause. J Reproductive Medicine, 2001;46(3 supl):317-324.

18. Knobf M. Natural menopause and ovarian toxicity associated with breast cancer therapy. Oncol Nurs Forum 25, 1998;(9):1519-1530; quiz 1531-1512

19. Rostom, A. The management of menopausal sequelae in patients with breast cancer. Clin Oncol (R Coll Radiol), 2001;13(3):174-80.

20. ABS 2002. http://agencysearch.australia.gov.au/search/search.cgi?query=infertility+rates&collection=agencies&form=simple&profile=abs

21. Domar A, Broome A, Zuttermeister P, Seibel M, Friedman R. The prevalence and predictability of depression in infertile women. Fertility Sterility 1992;58:1158-63.

22. Noorbala A, Ramezanzadeh F, Abedinia N, Naghizadeh M. Psychiatrid disorders among infertile and fertile women. Soc Psychiatry Psychiatr Epidemiol, 2009;44(7):587-91.

23. Volgsten H, Ekselius L, Poromaa I, Svanberg A. Personality traits associated with depressive and anxiety disorders in infertile women and men undergoing in vitro fertilisation treatment. Acta Obstet Gynecol Scand, 2010;89(1):27-34.

24. Gurhan N, Akyuz A, Atici D, Kisa S. Association of depression and anxiety with oocyte and sperm numbers and pregnancy outcomes during in vitro fertilisation treatment. Psychol Rep, 2009;104(3):796-806.

25. Drosdzol A, Skrzypulec V. Depression and anxiety among Polish infertile couples, an evaluative prevalence study. J Psychosom Obstet Gynecol, 2009;30(1):11-20.

Content Updated November 19, 2010