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Measures of health-related quality of life in PCOS

women: a systematic review
This article was published in the following Dove Press journal:
International Journal of Women’s Health

Zahra Behboodi Introduction: Polycystic ovary syndrome (PCOS) is associated with biochemical and hormonal
Moghadam 1 disturbance and adverse cosmetic, reproductive, metabolic, and psychological consequences,
Bita Fereidooni 2 resulting in reduced health-related quality of life (HRQoL). Various generic and specific ques-
Mohsen Saffari 3 tionnaires have been used for assessing different dimensions of HRQoL in PCOS women. The
Ali Montazeri 4 purpose of this systematic review was to identify those general and specific instruments and to
determine the factors that affect HRQoL in PCOS women.
1
Department of Reproductive Health,
School of Nursing and Midwifery,
Materials and methods: The research strategy involved general and specific terms in relation
Tehran University of Medical to PCOS women and their QoL. A review was performed on studies that were published between
Sciences, Tehran, Iran; 2Department 1945 to 2017 and that were indexed in MEDLINE, ISI Web of Science, and Scopus. A narrative
of Reproductive Health, School
of Nursing and Midwifery, Tehran synthesis of the data was provided.
University of Medical Sciences, Tehran, Results: In total, 52 studies (9 qualitative and 43 quantitative) were included in the review.
Iran; 3Health Research Center, Life The analysis indicated that 3 specific and 5 general instruments were used to measure the QoL
Style Institute, Baqiyatallah University
of Medical Sciences, Tehran, Iran; in PCOS women. Of these, the 36-Item Short Form Health Survey (SF-36) and the Polycystic
4
Population Health Research Group, Ovary Syndrome Health-Related Quality of Life Questionnaire (PCOSQ) were used most fre-
Health Metrics Research Center,
quently. All studies assessed different aspects of QoL in PCOS women and found that PCOS
Iranian Institute for Health Sciences
Research, ACECR, Tehran, Iran had negative effects on QoL in this population.
Conclusion: The PCOSQ and the SF-36 were used most frequently for the assessment of QoL
in PCOS women. Perhaps using either a specific questionnaire solely or a specific questionnaire
in conjunction with a generic measure would be more appropriate when measuring QoL in PCOS
women. However, both questionnaires showed that they are able to capture different aspects of
QoL in PCOS women and to identify areas that can help to improve QoL in these women.
Keywords: polycystic ovary syndrome, health-related quality of life, questionnaires, systematic
review

Introduction
Polycystic ovary syndrome (PCOS) is the most common hormonal disturbance that,
depending on the population studied and diagnostic criteria, affects up to 15%–20%
Correspondence: Bita Fereidooni of women at reproductive age.1,2 The pathophysiology of this heterogeneous disease
Department of Reproductive Health, has not been clearly determined, but it is believed that it results from complex interac-
School of Nursing and Midwifery,
Tehran University of Medical Sciences, tions between genetic, metabolic, and environmental factors.3 It is characterized by
Tohid Square, East Nosrat St, Tehran, Iran hyperandrogenism, ovulatory dysfunction, and polycystic ovarian morphology.4 PCOS
Email barshimah@yahoo.com
is associated with adverse clinical complications including reproductive (menstrual
Ali Montazeri irregularity and infertility),2,3 metabolic (insulin resistance, diabetes, and cardiovas-
Population Health Research Group,
Health Metrics Research Center, Iranian
cular risk),5 and psychological disabilities (anxiety and depression).6 All have been
Institute for Health Sciences Research, mentioned as factors responsible for the reduction of life quality.7
Academic Center for Education, Culture
and Research, Tehran, Iran
Health-related quality of life (HRQoL) is a multidimensional concept used to
Email montazeri@acecr.ac.ir describe physical, emotional, and social aspects of particular diseases or their treatment.8

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Chronic disorders such as PCOS may have major effects on Data synthesis
the QoL that need to be precisely assessed.9 Two authors were asked to go through the title and abstract
HRQoL can be assessed using both general and specific of the studies obtained and to read the full texts finally to
tools. General tools have generally no questions for specific decide which studies had met the criteria to be included in
conditions and diseases.10 Therefore, specific tools are gen- the current systematic review. The variables of interest were
erally preferable for each condition assessed, and PCOS is the first author’s name, year, country, study design, and study
no exception. However, both tool types have been used for results. The two authors negotiated any disagreements to
measuring QoL in the literature. The aims of this study were reach consensus.
to identify 1) studies that have used standard instruments to In order to assess HRQoL measures, the Consensus-based
measure HRQoL in women with PCOS; 2) general and spe- Standards for the Selection of Health Status Measurement
cific instruments that have been used for assessing HRQoL Instruments checklist was employed. Specifically, we
in PCOS women; and 3) the effects of PCOS on different assessed measures for the following criteria: internal con-
aspects of women’s QoL. sistency, reliability, content validity, construct validity, and
factor analysis.11
Methods
Search engines Results
The electronic databases searched included MEDLINE Statistics
(January 1950–March 2017), ISI Web of Knowledge In all, 4,269 citations were identified. After removing dupli-
(January 1945–26 July 2017), Scopus (May 2000–January cates (n=486), the remaining 3,783 citations were assessed,
2017), and Google Scholar (March 1996–January 2017). and an additional 3,161 irrelevant records were excluded. Of
More data were collected from the reference lists and data- the remaining 622 papers, 570 articles were also removed
bases related to scientific conference, and we contacted the because they were not eligible, and finally 52 full-text articles
authors of the publications to know they had any other studies were included in the analysis (Figure 1). Of these, 9 studies
which had remained unpublished. were qualitative and had focused upon the impact of PCOS
on patients’ HRQoL.12–20 The remaining 43 studies were
Search strategy quantitative which are summarized in Table 1. The frequency
In the current systematic review article, we managed to find of studies on QoL in PCOS women from various countries
general and specific instruments that assessed QoL, and we (n=52) was as follows: USA (n=13), UK (n=9), Iran (n=7),
further delineated the factors relevant to QoL in women suf- Australia (n=3), Germany (n=5), Sweden (n=2), Italy (n=2),
fering from PCOS using key words: (questionnaire OR scale Canada (n=2), the Netherlands (n=2), and Brazil (n=2). In
OR inventory) AND (“Quality of life” OR “Health-related addition, there was one article from each of the following
quality of life” OR “Patient-Reported Outcome”) AND countries: Belgium, Turkey, Austria, Taiwan, and Greece.
(“Polycystic ovary syndrome” OR “PCOS”). Table 2 displays and summarizes different components of
QoL in PCOS women.
Inclusion criteria
The following criteria were used to decide which relevant Instruments used
resources to be included: Various general and specific questionnaires were used to
1. Document type: article; assess QoL in PCOS women. Overall, three specific and
2. Article type: original, review, and theoretical; 5 general measures were used to assess the QoL in PCOS
3. Language: English; women. Of these, one general instrument (36-Item Short
4. Study design: qualitative, quantitative, and mixed Form Health Survey [SF-36]) and one specific instrument
methods; (Polycystic Ovary Syndrome Health-Related Quality of
5. Species: humans; Life Questionnaire [PCOSQ]) were used most frequently
6. Subject: health and medicine; (Table 3). The generic questionnaires were the following:
7. Documents’ subjects: QoL and its related factors in PCOS the SF-36 (n=17), Symptom Checklist-90-Revised
women; and (SCL-90-R; n=5), World Health Organization Quality-
8. Questionnaire used for HRQoL: measured more than one of-Life-BREF (WHOQOL-BREF; n=4), Child Health
dimension. Questionnaire-Child Form (CHQ-CF87; n=3), and General

398 submit your manuscript | www.dovepress.com International Journal of Women’s Health 2018:10
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Dovepress Factors affecting HRQoL in PCOS women

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Health Questionnaire-28 (n=1). The PCOS disease-specific women with PCOS, especially in adolescents.27,30–32 In two
instruments were the PCOSQ (n=20), the Modified PCOSQ more studies that were carried out in Australia and Germany,
(MPCOSQ; n=3), and the Polycystic Ovary Syndrome body weight domain was found to have the strongest asso-
Questionnaire (PCOSQ-50; n=1). In the following sections, ciation with lower QoL.33,34 The psychometric properties of
a short description for each of these is presented. PCOSQ are well documented in several studies indicating
that it is a reliable and valid measure for assessing QoL in
PCOSQ/MPCOSQ PCOS women.22,23,25,35 However, the PCOSQ was modified
The PCOSQ is an instrument that was specifically designed by Barnard et al, and 4 questions were added to it in order to
and validated to evaluate HRQoL in PCOS.21–23 In the first evaluate issues associated with acne.33 Thus, the MPCOSQ
stage of the instrument development, 182 items were incorpo- includes 30 questions from 6 HRQoL domains: emotional
rated which belonged to 8 areas chosen as a result of running disturbance (8 items), weight concerns (5 items), infertility
semi-structured interviews with 10 patients suffering from (4 items), acne (4 items), menstrual symptoms and predict-
PCOS and an extensive literature review.21 In item reduction ability (4 items), and hirsutism (5 items). Each item was rated
phase, 100 women with PCOS completed the instrument, on a 7-point Likert scale where higher scores represent better
and they identified the items of highest impact on their function. The psychometric properties of the MPCOSQ were
daily lives. By considering the factors influencing women promising.33 Using this instrument, Bazarganipour et al in a
and identifying the items that clinicians take as important, cross-sectional study of 300 women with PCOS found that
a factor analysis was performed, and the final questionnaire infertility and menstrual domains were the most affected
containing 26 items was provided. The PCOSQ contains the areas of HRQoL.36
following domains: emotions (8 items), hirsutism (5 items),
weight (5 items), infertility (4 items), and menstrual disorders PCOSQ-50
(4 items). Each item can be answered by choosing from a The PCOSQ-50 was specifically developed by Nasiri-Amiri
Likert scale with 7 options from 1 (always) to 7 (never). et al for measuring QoL in PCOS women.37 They used a
Higher scores are indicative of better function. Studies that mixed-method, sequential, exploratory design to define the
incorporated the PCOSQ revealed that women with PCOS components of health-related QoL questionnaire and assessed
had functioning impairments pertinent to some measured the psychometric properties of instrument. A rudimentary
domains.24–29 However, the relative degree of impairment questionnaire composed of 147 items was designed drawing
caused by each domain varied in societies depending on the on the findings of a qualitative study that was carried out with
religious, racial, cultural, and social factors.24 Excess body 23 Iranian women who suffered from PCOS. Exploratory
weight has been widely reported as an important concern to factor analysis helped to reduce the number of items from

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 Table 1 Quantitative studies that measured HRQoL of women with PCOS (n=43)

400
Study; country Design Objective Diagnosis Age (years, mean ± HRQoL Sample size Main outcomes
criteria SD) instruments
used
Cronin et al;21 Cross-sectional Designing tools for measuring the QoL in NIH 18–45 PCOSQ 100 PCOS; Developing PCOSQ, which includes

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USA women with PCOS 12 interviews 26 items
Wong et al;65 Cross-sectional Examining the relative impact of the number Not stated 30.5±6.7 PCOSQ 100 Including all potential items in calculating
Behboodi Moghadam et al

Canada and severity of patient problems on HRQoL a domain score provided a more accurate
portrait of HRQoL
Trent et al;52 USA Cross-sectional Evaluating the HRQoL in adolescents with NIH 13–22 CHQ-CF87 146 control, Patients had worsened QoL. Patients with
PCOS and its correlation with patients’ 97 PCOS higher self-perceived severity scored were
perception lower on the general health perception

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Trent et al;66 USA Cross-sectional Evaluating the fertility concerns and sexual NIH 13–22 CHQ-CF87 146 control, PCOS women were 3.4 times more likely
behavior in young PCOS women compared 97 PCOS to be worried about fertility issues
with healthy women
Elsenbruch et al;30 Case–control Evaluating the quality of life, mental status, NIH Controls: 29.9±5.7; SF-36, SCL-90-R 50 control, PCOS caused a major reduction in the
Germany and sexual satisfaction in PCOS women PCOS: 28.4±5.0 50 PCOS QoL and severely limits sexual satisfaction
Hashimoto Case–control Evaluating the impact of weight status on NIH Brazilian: 25.5±3.9; PCOSQ 50 control, In Brazilian women, hirsutism and in
et al;67 Brazil symptom perception and QoL in PCOS Austrian: 23.8±4.7 50 PCOS Austria obesity had the greatest impact
women with different background on QoL
Guyatt et al;22 Cross-sectional Measuring the psychometric properties of NIH 29.4±5.7 PCOSQ 393 Factor analysis provided moderate to
Canada the PCOSQ strong support for the 5-domain structure
of the PCOSQ
Schmid et al;24 Cross-sectional Study of infertile PCOS patients QoL with Not stated 18–39 PCOSQ 14 Muslim, 35 HRQoL of women with an Islamic
Austria different ethnic and cultural backgrounds Austrian PCOS background was affected to a greater
degree than that of Austrian women
Jones et al;23 UK Cross-sectional Measuring the psychometric properties of NIH – PCOSQ, SF-36 92 The PCOSQ is a reliable instrument for
the PCOSQ measuring the HRQoL
Van Wely et al;68 Interventional Evaluating the impact of laparoscopic Rotterdam Electrocautery: 28.5±3.7; SF-36 Electrocautery: HRQoL was not affected in both groups.
the Netherlands electrocautery of the ovaries versus FSH: 28.7±4.1 83, FSH: 85 FSH treatment was slightly more
recombinant FSH on the PCOS patients’ burdensome for women’s HRQoL than
HRQoL electrocautery
Clayton et al;69 Interventional Evaluation the effect of laser on the severity Not stated PCOS: 33.0±8.0; WHOQOL-BREF 37 control, 51 Laser treatment reduced the severity of
UK of facial hirsutism and on psychological control: 32±6.5 intervention facial hair as well as alleviating depression
complications in PCOS women and anxiety in patients
McCook et al;27 Cross-sectional Evaluating the influence of the major clinical Not stated 20–41 PCOSQ 128 The most common HRQoL concern
USA features of PCOS on patients’ QoL reported by women with PCOS was
weight. BMI and fertility loss had the
greater impact on QoL
Trent et al;53 USA Cross-sectional Assessing the BMI impact on the QoL of NIH 13–22 CHQ-CF87 146 control, BMI is a primary mediator in the
adolescents with PCOS 97 PCOS relationship between PCOS and HRQoL
reductions

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 Hahn et al;47 Case–control Examining the extent of different PCOS NIH PCOS: 29.0±5.4; SF-36, SCL-90-R 120 control, PCOS patients showed significant
Germany manifestations on QoL, psychosocial well- control: 30.0±5.7 50 PCOS reductions in QoL, psychosocial well-being,
being, and sexual satisfaction and sexual satisfaction
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Elsenbruch et al;40 Cross-sectional Evaluation of psychological stress in NIH 31.3±1.3 SF-36, SCL-90-R 143 Majority of patients exhibited psychological
Germany untreated PCOS patients and to assess the disturbances. Emotional distress together
impact of emotional distress on QoL with obesity leads to large decrements in
QoL
Lipton et al;70 UK Cross-sectional Assessing the behavioral and psychological Not stated 33.0±7.4 WHOQOL-BREF 88 Facial hair carries a high psychological
burden of facial hair in PCOS women burden for women. 29% of patients
reported depression and anxiety
Coffey et al;25 UK Case–control Comparing the QoL in women with PCOS AES PCOS: 27.5; control: SF-36, PCOSQ 22 control, PCOS had a negative impact on HRQoL
with the general population and patients 28.8 96 PCOS even when compared with other medical
with other medical conditions conditions (asthma, epilepsy, diabetes,
arthritis, and coronary heart disease)

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Hahn et al;39 Interventional Evaluation the effects of metformin NIH 29.3±6.3 SF-36, SCL-90-R 327 Treatment improved the psychosocial,
Germany treatment on HRQoL, emotional well-being, Rotterdam emotional, and psychosexual situation of
and sexuality in PCOS women PCOS patients
Barnard et al;33 Cross-sectional Assessing the quality of life of women with Rotterdam 31.0±6.5 MPCOSQ 935 control, The PCOSQ was modified to include acne.
UK PCOS, studying the factor analysis and 424 PCOS The PCOS groups had significantly worse
adding acne factor QoL than controls
Drosdzol et al;60 Case–control To evaluate the effect of PCOS on QoL and Rotterdam 19–40 SF-36 40 control, PCOS decreased QoL and sexual
the Netherlands marital sexual satisfaction 50 PCOS functioning among women. A negative
effect of hirsutism severity on general well-
being and sexual life was also observed
Ching et al;26 Case–control Evaluation of QoL and psychological NIH PCOS: 15–65; control SF-36, PCOSQ, 173 control, Impaired QoL and increased prevalence of
Australia complications in PCOS women, compared 18–44 GHQ-28 203 PCOS psychological morbidity in PCOS compared
the findings with general norms with population norms were obtained
Tan et al;48 Cross-sectional Assessing the impact of infertility on various NIH 28.1±4.8 SF-36, SCL-90-R 115 PCOS obtained a major risk factor for
Germany aspects of psychological function in PCOS psychosocial and emotional problems.
women Infertility was not a primary determinant of
psychological problems
Rofey et al;41 USA Interventional Evaluating cognitive–behavioral therapy on AES 12–18 SF-36 25 Depressive symptoms and weight
psychological problems of PCOS adolescents decreased significantly
Harris-Glocker Interventional Assessing the effect of treatment NIH 12–18 PCOSQ 36 QoL was improved in both groups (lifestyle
et al;71 USA (metformin, lifestyle) on the QoL in obese and obsessive–compulsive disorder
PCOS adolescents treatment)
Ladson et al;72 Interventional Assessing the effect of treatment NIH 13–18 PCOSQ 28 QoL was significantly improved in both
USA (metformin, lifestyle) on the QoL of treatment groups
adolescents with PCOS
Moran et al;73 Case–control Evaluating the psychological features in Rotterdam 18–25 PCOSQ 22 control, Worsened QoL in PCOS women
Australia young girl with PCOS compared with 24 PCOS

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healthy women
(Continued)

401
Factors affecting HRQoL in PCOS women
 Table 1 (Continued)

402
Study; country Design Objective Diagnosis Age (years, mean ± HRQoL Sample size Main outcomes
criteria SD) instruments
used
Thomson et al;34 Interventional Assessing the effect of exercise and dietary Rotterdam 29.3±0.7 PCOSQ 104 Dietary restriction, with/without exercise,

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Australia restriction on depressive symptoms and had similar benefits for improving
HRQoL in obese women with PCOS depression and HRQoL in obese women
Behboodi Moghadam et al

with PCOS
Ladson et al;74 Interventional Determining the effect of lifestyle changes NIH 29.0±4.5 PCOSQ 114 QoL was improved in emotion and weight
USA (caloric restriction and exercise) on the areas within each treatment group
QoL of PCOS women
Bazarganipour Cross-sectional Assessing the prevalence of mood disorders Rotterdam 15–40 SF-36 300 32% of patients showed elevated anxiety

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et al;75 Iran and examine predictors for psychological and depression. QoL was very impaired in
well-being among Iranian PCOS women women with anxiety and depression
Bazarganipour Cross-sectional Evaluating the effect of different clinical Rotterdam 15–40 MPCOSQ 200 Worsened HRQoL in PCOS women was
et al;76 Iran symptoms of PCOS on patients HRQoL related to more menstrual problems and
infertility than to obesity
Stener-Victorin Interventional The effect of exercise and acupuncture on Rotterdam 29.9±4.4 SF-36, PCOSQ 114 Anxiety and depression improved in
et al;77 Sweden the QoL in PCOS women women treated with acupuncture. HRQoL
was improved in both groups
Bazarganipour Cross-sectional Determining the association between Rotterdam 15–40 MPCOSQ 300 The highest effect of PCOS symptoms on
et al;78 Iran HRQoL and psychosexual variables in HRQoL was exerted by clinical variables,
patients with PCOS poor perception, negative body image, and
sexual dysfunction
De Frène et al;79 Cross-sectional Investigating the relationship between Rotterdam 18–43 PCOSQ 62 PCOS characteristics and its concerns
Belgium PCOS symptoms with sexual and relational were associated with the sexual and/or
satisfaction in obese women and their relational satisfaction of couples
partners
McCook et al;28 Cross-sectional Investigating the relative contributions Rotterdam 18–48 PCOSQ 126 Patients were at a greater risk for
USA of PCOS manifestations to psychological depression, anxiety, and interpersonal
symptoms sensitivity. Menstrual problems predicted
every dimension of psychological distress
Benetti-Pinto Case–control Assessing the sexual function and QoL in Rotterdam PCOS: 26.9±4.9; WHOQOL-BREF 102 control, PCOS women had a worse sexual function
et al;50 Brazil PCOS women control: 35.6±7.3 56 PCOS and worse QoL in the self-assessment of
the health area. Obesity was correlated to
the worsening in QoL
Guidi et al;80 Italy Cross-sectional Assessing the psychosocial effects of PCOS NIH 16–19 PCOSQ 394 Impaired well-being and QoL were found
on adolescents among young females with PCOS
Stefanaki et al;81 Interventional The effect of mindfulness – stress program Rotterdam 15–40 PCOSQ 73 Stress, anxiety, and depression levels
Greece on mental status and QoL in PCOS women decreased and QoL improved
Nasiri-Amiri Mixed methods Designing HRQoL measurement tool in Rotterdam 18–40 PCOSQ-50 200 PCOS, The PCOSQ-50 was a valid and reliable
et al;37 Iran Iranian women with PCOS 23 interviews instrument for the assessment of QoL of
women with PCOS

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Dovepress Factors affecting HRQoL in PCOS women

Table 2 Different components of quality of life in PCOS women

Abbreviations: AES, Androgen Excess Society; BMI, body mass index; CHQ-CF87, Child Health Questionnaire-Child Form; FSH, follicle-stimulating hormone; GHQ-28, General Health Questionnaire-28; HRQoL, health-related quality
of life; MPCOSQ, Modified PCOSQ; NIH, National Institutes of Health; PCOS, polycystic ovary syndrome; PCOSQ, Polycystic Ovary Syndrome Health-Related Quality of Life Questionnaire; PCOSQ-50, Polycystic Ovary Syndrome
with controls. QoL was significantly lower
rates of depressive and anxious compared
women especially in overweight patients

Worsening of HRQoL in PCOS patients

groups, but these impaired effects were
Dimensions Studies

Metformin improved HRQoL of PCOS

PCOS patients had significantly higher

The physical aspects of HRQoL were

improvements in several physical and

adversely affected by obesity in both Psychological McCook et al,27 Coffey et al,25 Elsenbruch et al,40

mental domains related to QoL

and emotional Jedel et al,85 Teede et al,3 Månsson et al,86 McCook

Weight loss result in significant

et al,28 Podfigurna-Stopa et al,62 Weiss and Bulmer,16
Bazarganipour et al,75 Nasiri Amiri et al,87 and

compared with controls

greater in PCOS group

Taghavi et al19
Body image Trent et al,66 Ekbäck et al,14 Bazarganipour et al,75 and
Taghavi et al19
Social Trent et al,66 Jones et al,23 Schmid et al,24 Ekbäck

in patients
et al,14 Moran et al,73 Bazarganipour et al,75 Taghavi
et al,19 and Weiss and Bulmer16

Questionnaire; QoL, quality of life; SCL-90-R, Symptom Checklist-90-Revised; SF-36, 36-Item Short Form Health Survey; WHOQOL-BREF, World Health Organization Quality-of-Life-BREF.
Sexual Elsenbruch et al,30 Trent et al,66 Tan et al,48 Månsson
et al,86 Benetti-Pinto et al,50 and Taghavi et al19
140 control,

Physical
38 control,

80 control,
142 PCOS

100 PCOS
53 PCOS

Weight Barnard et al,33 Hahn et al,43 Elsenbruch et al,30

Kaczmarek et al,32 Trent et al,53 Benetti-Pinto et al,50
109

149

and Shishehgar et al42

Hirsutism Elsenbruch et al,30 Ekbäck et al,14 and Khomami et al29
SF-36, PCOSQ,
SF-36, PCOSQ
BREF, PCOSQ

and acne
WHOQOL-

Menstrual Bazarganipour et al,36 Bazarganipour et al,75 McCook

SCL-90-R

problem et al,27 and McCook et al28

SF-36

SF-36

Infertility Schmid et al,24 Elsenbruch et al,30 Hahn et al,43

Bazarganipour et al,75 Nasiri Amiri et al,61 and
Khomami et al29
Medical Van Wely et al,68 Hahn et al,39 Trent et al,53 Hahn
Rotterdam Controls: 16.4–31;

et al,39 Thomson et al,34 Harris-Glocker et al,71

control: 29.0±5.8

control: 21.3±2.1
PCOS: 28.6±4.9;

Rotterdam PCOS: 22.6±4.5;

PCOS: 17.2–29

Dokras et al,83 Stefanaki et al,81 and Rofey et al41

Abbreviation: PCOS, polycystic ovary syndrome.
Rotterdam 18–45

Rotterdam 18–40

147 to 50. The ultimate draft of the questionnaire incorpo-

rated 50 items representing 6 areas, namely emotion, obesity
and menstrual disorders, fertility, sexual function, hirsutism,
AES

and coping. Each item could be answered by selecting from

options on a 5-point Likert scale with higher scores meaning
Effect of metformin on the QoL of women

mood disorders and QoL in obese women

HRQoL between women with PCOS and

Comparing the QoL in obese and normal

Evaluation of the effect of weight loss on

Assessment of temperament and QoL in

Comparing the effects of obesity on the

better condition. The analysis of the psychometric properties

of the questionnaire revealed promising results.
weight women with PCOS

SF-36
The SF-36 is one of the most acknowledged and most fre-
quently used instruments to measure QoL. The SF-36 is
PCOS patients

used in all types of patients and has been validated in many

with PCOS

with PCOS
controls

countries. This instrument has been proved to be reliable and

widely validated and has been employed in the assessment of
HRQoL in various medical conditions. It consists of 36 items
Interventional

Interventional
Shishehgar et al;42 Case–control

Case–control

Case–control

tapping into 8 subscales, namely physical functioning, role

physical, bodily pain, general health, vitality, social func-
tioning, role emotional, and mental health.38 The scores on
each domain range from 0 to 100 where the higher scores
indicate better conditions. Several studies used the SF-36
Dokras et al;83
et al;82 Taiwan

et al;84 Turkey

Panico et al;44
Huang-TzOu

in order to assess HRQoL in PCOS patients.30,39–42 Findings

Ozcan Dag

have been rather consistent in revealing lower HRQoL in

USA

Italy
Iran

women suffering from PCOS. However, evidence suggests

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Behboodi Moghadam et al Dovepress

Table 3 Most general and specific instruments for assessing HRQoL in women with PCOS
Instruments No of Dimensions covered Studies
items
General instruments
SF-36 36 Physical functioning, vitality/energy, physical role Elsenbruch et al,30 Jones et al,23 Van Wely et al,68 Hahn et al,47
limitation, bodily pain, mental health, emotional Hahn et al,39 Elsenbruch et al,40 Coffey et al,25 Drosdzol
role limitation, general health perception, and social et al,60 Ching et al,26 Tan et al,48 Rofey et al,41 Bazarganipour
functioning et al,75 Stener-Victorin et al,77 Dokras et al,83 Shishehgar
et al,42 Ozcan Dag et al,84 and Panico et al44
SCL-90-R 90 Somatization, obsessive–compulsive, interpersonal Elsenbruch et al,30 Hahn et al,47 Hahn et al,39 Elsenbruch et al,40
sensitivity, paranoid ideation, psychoticism, anxiety and Tan et al48
depression, phobia, and aggression
CHQ-CF87 87 Change in health in the last year, role/social Trent et al,52 Trent et al,66 and Trent et al53
emotional, behavioral, physical, bodily pain,
behavior, mental health, self-esteem, general health
perceptions, family activities, family cohesion, and
physical functioning
WHOQOL-BREF 26 General health, physical health, psychological, Clayton et al,69 Lipton et al,70 Benetti-Pinto et al,50 and
health, Social relationship, and environmental Huang-TzOu et al82
GHQ-28 28 Somatic symptom, anxiety/insomnia, social Ching et al26
dysfunction, and depression
Specific instruments
PCOSQ 26 Emotion, hirsutism, infertility, weight, and menstrual Cronin et al,21 Wong et al,65 Hashimoto et al,67 Guyatt
problem et al,22 Jones et al,23 Schmid et al,24 McCook et al,27 Coffey
et al,25 Ching et al,26 Rofey et al,41 Harris-Glocker et al,71
Moran et al,73 Thomson et al,34 Ladson et al,72 Stener-Victorin
et al,77 De Frène et al,79 Stefanaki et al,81 McCook et al,28
Dokras et al,83 and Panico et al44
MPCOSQ 30 Emotion, hirsutism, infertility, weight, menstrual Barnard et al,33 Bazarganipour et al,36 and Bazarganipour et al78
problem, and acne
PCOSQ-50 50 Psychosocial and emotional, fertility, sexual, obesity, Nasiri-Amiri et al37
and menstrual disorders, hirsutism, and coping
Abbreviations: CHQ-CF87, Child Health Questionnaire-Child Form; GHQ-28, General Health Questionnaire-28; HRQoL, health-related quality of life; MPCOSQ, Modified
PCOSQ; PCOS, polycystic ovary syndrome; PCOSQ, Polycystic Ovary Syndrome Health-Related Quality of Life Questionnaire; PCOSQ-50, Polycystic Ovary Syndrome
Questionnaire; SCL-90-R, Symptom Checklist-90-Revised; SF-36, 36-Item Short Form Health Survey; WHOQOL-BREF, World Health Organization Quality-of-Life-BREF.

that poor QoL in these women might be due to obesity. In sensitivity, depression, anxiety, aggression, phobia, paranoid
some studies, it has been shown that body mass index (BMI) ideation, psychoticism, and sleep disorders.46 Three global
was a predictor of physical functioning as measured by the areas are measured, including the Global Severity Index,
SF-36.43,44 Furthermore, by using a multivariable regression Positive Symptom Distress Index, and Positive Symptom
model, Panico et al in a recent study indicated that BMI is a Total. For each item related to a single domain, a score
predictor of physical functioning score.44 Jones et al found ranging from 0 (not at all) to 4 (very much) can be selected.
that the role emotional was the poorest area of health, with Higher scores represent less favorable conditions.44 Some
mean scores of 50.4 on the SF-36 questionnaire, which studies targeting adult women suffering from PCOS have
had the greatest negative impact on HRQoL in women employed the SCL-90 to measure life quality.30,40,44,47,48 By
with PCOS.23 In a study by Coffey et al, the psychological using this tool, Elsenbruch et al showed that emotional
dimension was more affected than the physical dimension distress and obesity in PCOS women are associated with
as measured by the SF-36.25 Bazarganipour et al found that significant decrease in HRQoL.40
PCOS affected all domains in the SF-36, and psychological
domains were most affected by PCOS.45 WHOQOL-BREF
WHOQOL-BREF instrument is comprised of 26 items,
SCL-90-R which measure broad domains consisting of physical health,
The SCL-90 has also been widely used and extensively vali- psychological health, social relationships, and environment.
dated. It includes 90 items grouped into 10 main domains, The WHOQOL-BREF is a shorter version of the original
namely somatization, obsessive–compulsive, interpersonal instrument and can be used for assessing the QoL in different

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Dovepress Factors affecting HRQoL in PCOS women

cultures and populations. In a study on 146 women having weight has been widely reported as an important concern to
PCOS and 170 controls who were assessed by the WHOQOL- women with PCOS, especially in adolescents.27,30–32 Obesity
BREF questionnaire, it was discovered that the hirsutism is believed to be a primary source for poor HRQoL and con-
scores were a major predictor of psychological distress and tributes substantially to negative psychological symptoms in
showed correlation with the emotion domain.49 In Benetti- women with PCOS.54 The findings of an Italian study that
Pinto et al’s study, the BMI was inversely correlated to the was recently performed yielded a significant aggravation
QoL in women suffering from PCOS, mainly with the physi- of HRQoL in PCOS patients with obesity compared with
cal, psychological, and environmental aspects of QoL.50 controls.44
Hirsutism can be found in nearly 70% of women suffering
CHQ-CF87 from PCOS,2 and patients take it as one of the most annoy-
The CHQ-CF87 is a self-report questionnaire that was devel- ing aspects of PCOS.29,55 Women suffering from PCOS who
oped and validated at the Health Institute of the New England experience hirsutism have often complained that they feel
Medical Center in Boston.51 It has been used to measure “unfeminine.”12,30,56,57
HRQoL in general populations of youth. It consists of 12 The comparison of psychological well-beings between
summated scales and is designed to measure both the physical women suffering from PCOS and control groups showed an
and psychosocial HRQoL of adolescents. The items on the increased risk for emotional distress in those with PCOS.6
CHQ-CF87 are scored from 0 to 100 except for the change Recent meta-analysis in PCOS women has yielded a raise in
in health in the last year, and the items on family cohesion the prevalence of both depressive and anxiety symptoms in
subscales are scored from 1 to 5 as single-item measures. women suffering from PCOS in comparison with controls.58
A higher score on each subscale indicates better QoL in a Loss of femininity, body image concerns, and coping with
specific area or health improvement in the last year. these conditions may all contribute to poorer mental health
Trent et al in their study used the CHQ-CF87 and revealed outcomes.59
that HRQoL scores of adolescents suffering from PCOS Moreover, changes in body dimensions and physical
were significantly lower in 4 areas of physical functioning, beauty as well as imbalance of sexual hormones could lead
general health perceptions, behavior, and family activities as to reduction in QoL and sexual performance. Psychological
measured by the questionnaire.52 These authors also carried distress from long-term health risks, infertility, and changes
out another study in this area and evaluated the influence in appearance (obesity, acne, and hirsutism) can influence
of BMI on QoL disturbances in adolescent patients. PCOS sexual function among PCOS women.50,60 These women often
adolescents had higher BMI than those of the controls and complain that they feel less attractive and being less sexually
a significantly lower HRQoL. Similarly, PCOS girls scored satisfied in comparison with non-PCOS women.30
lower on the general health perceptions, physical function- PCOS can also affect patients’ QoL socially. Based
ing, family activities, and the general behavior subscales of on the results of qualitative studies, other factors that
CHQ-CF87.53 affected QoL were the reduction of interpersonal and social
relationships.61,62 Accordingly, Ekbäck et al in their qualita-
Discussion tive study showed that hirsutism causes severe psychological
The studies identified in this review have shown that PCOS burden and negatively affected patients’ HRQoL and social
is a major cause of psychological morbidity and has a interactions.14 A few studies explored the impact of treatment
negative impact on women’s HRQoL. This feature has also on HRQoL. In 2009, Rofey et al showed that an enhanced
been demonstrated in some qualitative studies.13,14,16,19 In all cognitive behavioral therapy was practical and encouraging
the studies reviewed, different aspects of the QoL in PCOS for adolescents suffering from PCOS.41
women were evaluated including physical, psychological, One of the major findings of the current research was
social, sexual as well as medical ones. the high frequency of application of specific and general
The impact of PCOS on the HRQoL may be more instruments such as PCOSQ and SF-36. In our review,
specifically seen in the perception of values and culture;24 24 studies had used specific tools for this purpose, and
therefore, the major contributing factors of reductions of life general questionnaires had been applied in other studies.
quality in PCOS were discovered to be different in a variety PCOS affects women both psychologically and physically
of population. However, physical aspects of QoL may be according to the SF-36. A recent meta-analysis showed that
best predicted by obesity and hirsutism.29,49 Excess body women with PCOS score lower in each dimension of the

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Behboodi Moghadam et al Dovepress

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