Polycystic ovary syndrome is associated
with negatively variable impacts on domains
of health-related quality of life: evidence
from a meta-analysis
Yanan Li, M.M.,a Yan Li, M.D., Ph.D.,a Ernest Hung Yu Ng, M.D.,b Elisabet Stener-Victorin, Ph.D.,a,c
Lihui Hou, M.D.,a Taixiang Wu, M.D., Ph.D.,d Fengjuan Han, M.D., Ph.D.,a and Xiaoke Wu, M.D., Ph.D.a
a
Department of Obstetrics and Gynecology, National Key Laboratory and Unit of Infertility, Clinical Trial Base, First Affiliated
Hospital, Heilongjiang University of Chinese Medicine, Harbin, People’s Republic of China; b Department of Obstetrics and
Gynecology, University of Hong Kong, Hong Kong, People’s Republic of China; c Institute of Neuroscience and Physiology,
Department of Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; and d Chinese Clinical
Trial Registry, Chinese Evidence-Based Medicine Centre, Chinese Cochrane Centre, INCLEN CERTC, West China Hospital,
Sichuan University, Chengdu, People’s Republic of China
Objective: To systematically review the literature to identify the impact of polycystic ovary syndrome (PCOS) on
specific health-related quality of life domains.
Design: Meta-analysis.
Setting: N/A.
Patient(s): The outcomes of 423 patients and 285 controls from 5 articles that used the Short Form 36 (SF-36)
questionnaire were used for meta-analysis.
Intervention(s): N/A.
Main Outcome Measure(s): The SF-36 dimensions including physical function, physical role function, body pain,
general health, vitality, social function, emotional role function, and mental health were evaluated.
Result(s): Compared with controls, women with PCOS had lower scores in all SF-36 dimensions: physical function
(mean differences [MD], 5.46; 95% confidence intervals [CI], 8.52, 2.41), physical role function (MD, 5.76;
95% CI, 8.49, 3.03), body pain (MD, 4.55; 95% CI, 7.99, 1.11), general health (MD, 11.34; 95% CI,
19.53, 3.15), vitality (MD, 15.14; 95% CI, 17.43, 12.84), social function (MD, 15.95, 95% CI, 18.57,
13.33), emotional role function (MD, 23.86; 95% CI, 27.51, 20.21), and mental health (MD, 13.83; 95% CI,
16.13, 11.53).
Conclusion(s): The meta-analysis showed that women with PCOS score lower in each dimension of the SF-36,
mostly in the emotional role function. (Fertil Steril 2011;96:452–8. 2011 by American Society for
Reproductive Medicine.)
Key Words: Polycystic ovary syndrome, SF-36, quality of life, meta-analysis
Polycystic ovary syndrome (PCOS) is a common endocrine disorder
affecting 5% to 10% of women of reproductive age (1). Its etiology is
unknown, and its presentation varies (2). According to the Rotterdam
consensus (3), the diagnosis of PCOS requires at least 2 of the following 3 conditions: [1] oligoovulation or anovulation, [2] clinical
and/or biochemical signs of hyperandrogenism, and [3] polycystic
ovaries and the exclusion of other etiologies. PCOS is associated
Received March 16, 2011; revised May 20, 2011; accepted May 23, 2011;
published online June 24, 2011.
Y.L. has nothing to disclose. Y.L. has nothing to disclose. E.H.Y.N. has
nothing to disclose. E.S-V. has nothing to disclose. L.H. has nothing
to disclose. T.W. has nothing to disclose. F.H. has nothing to disclose.
X.W. has nothing to disclose.
Supported by the National Clinical Trial Base of Chinese Medicine in
Gynecology (http://www.satcm.gov.cn/zhuanti/lcyjjd/tzgg/20090519/
130039.shtml), National Public Welfare Projects for Chinese Medicine
(201107005; 200807021).
Yanan Li and Yan Li contributed equally to this work.
Reprint requests: Xiaoke Wu, M.D., Ph.D., or Fengjuan Han, M.D., Ph.D., Department of Obstetrics and Gynecology, National Key Laboratory and Unit
of Infertility, Clinical Trial Base, First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin 150040, People’s Republic of China
(E-mail: xiaokewu2002@vip.sina.com or hanfengjuan2004@163.com).
452
with several mental health problems, including depression and anxiety (4–10), suicide attempts (11, 12), body dissatisfaction (13), eating disorders (14–18), diminished sexual satisfaction (19–21), and
lowered health-related quality of life (HRQoL) (22, 23). Because
treatment for PCOS is symptom oriented, individualized
management should be aimed at relieving symptoms and
improving HRQoL.
In its 1946 constitution, the World Health Organization defined
health as ‘‘a state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity’’ (WHO
definition of Health, Preamble to the Constitution of the World
Health Organization as adopted by the International Health Conference, 1946). This definition represented a departure from defining
health solely in terms of death and disease. Later, HRQoL was defined as the ‘‘physical, psychologic and social domains of health,
seen as distinct areas that are influenced by a person’s experiences,
beliefs, expectations and perceptions’’ (24). HRQoL assessments
have an important role in measuring chronic disease (25) and may
assist in clinical decision making regarding choice of treatment
and policy decisions. Furthermore, randomized controlled trials
now often include HRQoL measures as valid and useful end points
along with traditional clinical outcomes (26).
Fertility and Sterility Vol. 96, No. 2, August 2011
Copyright ª2011 American Society for Reproductive Medicine, Published by Elsevier Inc.
0015-0282/$36.00
doi:10.1016/j.fertnstert.2011.05.072
PCOS is a metabolic, hormonal, and psychosocial disorder that adversely affects a patient’s quality of life (10, 27, 28). Jones et al. (29)
performed a systematic review focusing specifically on HRQoL measurement in women with PCOS. However, the relative degree of impairment in each domain differed among samples, and it was not clear
which aspect of HRQoL was most negatively affected. In this study,
our goal was to systematically review the effects of PCOS on specific
HRQoL domains compared with the results of healthy controls.
MATERIALS AND METHODS
Search Strategy
To identify eligible studies, we searched the electronic databases MEDLINE,
EMBASE, CINAHL, EMBR, CNKI, Wanfang, and Vip from inception
through December 2009, using the terms (‘‘quality of life’’ [MeSH] OR
‘‘health-related quality of life’’ OR ‘‘health status measurement’’ OR ‘‘subjective health status’’ OR ‘‘quality of life questionnaire’’) AND (‘‘polycystic
ovary syndrome’’ [MeSH] OR ‘‘polycystic ovarian syndrome’’ OR ‘‘polycystic ovaries’’). The search was restricted to literature in English and Chinese.
We then perused the reference sections of all relevant studies or reviews, manually searched key journals and abstracts from major annual meetings in the field
of endocrinology, and contacted experts on the subject in an effort to identify relevant unpublished data. The data search and screening of titles, abstracts, and
full-text articles were completed independently by 2 reviewers (Yanan Li and
Yan Li). Any discrepancy was solved by consultation with a third reviewer (Ng).
Eligibility of Relevant Studies
Studies that reported HRQoL in women with PCOS and healthy, agematched controls were considered suitable for this review. Studies were excluded if they appraised a single dimension because HRQoL is defined as
a multidimensional concept that encompasses physical, emotional, and social
aspects associated with a disease or its treatment. Studies that used ad hoc
questionnaires/instruments were also excluded, as were reviews, letters to
the editor, and studies using data from the same group. If the outcomes for
which we were looking were not reported in the study, the study authors
were contacted to ask for additional information; the trials were excluded
if additional information was not available.
Data Extraction
Information from each study was extracted independently by 2 reviewers
(Yanan Li and Yan Li), using a piloted data extraction form. General characteristics of the study (author, journal, year of publication, design, ethnicity,
study size, and number of cases), characteristics of the PCOS and control
groups (selection criteria, age, body mass index [BMI], androgen levels,
Ferriman-Gallway score, and global acne score), methodology (HRQoL measurement method, study quality), and results (means SD) were recorded
when available and double-checked. If necessary, the data set was completed
through communication with the authors. Two reviewers (Yanan Li and Yan
Li) assessed the quality of included studies using the Newcastle-Ottawa scale
for assessing the quality of nonrandomized studies in meta-analysis (30).
RESULTS
Search Results
The search strategy identified 746 studies (Fig. 1). A total of 703
publications were excluded because they were repetitions, appeared
in more than 1 database, or were not relevant or specific to the study
topic, as judged from the title, abstract, and full text. Eleven studies
were excluded because they were reviews or letters to the editors or
because the full text was not available. Of the remaining 32 studies,
16 had no healthy control group and were excluded (31–46). Eight
studies were excluded because insufficient data were available; in
5 studies (22, 23, 47–49), the results were presented only as
medians or in figures and no additional results were obtained after
contact with the original authors. In one study (50), results were presented only in physical sum and psychologic sum but not in every
dimension; in 2 studies (51, 52), in-depth semistructured interviews
rather than self-report questionnaires were used. Two studies (53,
54) were excluded because the CHQ-CF87 scores coincided with
those in a previous study by the same authors (55), suggesting sample duplication. Finally, 5 studies (19, 20, 28, 56, 57) using the same
questionnaire, Short Form-36 (SF-36), were included in the metaanalysis.
Description of Studies
The characteristics of the included studies are briefly described in
Table 1. One study reported that a significantly greater proportion
of patients with PCOS currently had an unfulfilled wish to conceive
a child (PCOS, 42%; controls, 6%) (19). Another study reported
statistically significant differences related to the number of pregnancies, miscarriages, and infertility problems. With respect to pregnancies, a higher percentage of women who were pregnant and had
delivered children was noted among healthy women (82.5%) in
comparison with 24.0% of women with PCOS (P<.05). Six percent
of women with PCOS had miscarriages in their medical history, and
50.0% of this group was diagnosed and treated for infertility,
whereas no miscarriages or infertility problems were found in the
control group (20).
FIGURE 1
Flow chart for the systematic review.
Statistical Analysis
The scores on questionnaires used to evaluate HRQoL in women with PCOS
and controls in each study were extracted as mean differences (MD) SD.
MD and 95% confidence intervals (CI) were calculated for scores in all
studies eligible for the meta-analysis and combined by using fixed- or
random-effects model (DerSimonian–Laird random-effects method), when
appropriate. Statistical heterogeneity in the results of different studies was
examined by c2 tests for significance. P<.05 was considered statistically
significant. Inconsistency across studies was quantified with the value of
I2. A rough guide to interpretation of I2 is as follows: 0% to 40%, might
not be important; 30% to 60%, may represent moderate heterogeneity;
50% to 90%, may represent substantial heterogeneity; and 75% to 100%,
considerable heterogeneity. To assess the extent of publication bias, a funnel
plot may be used. The meta-analysis was conducted with Review Manager
(version 5.0.25).
Fertility and Sterility
Li. HRQoL in women with PCOS. Fertil Steril 2011.
453
454
Li et al.
TABLE 1
HRQoL in women with PCOS
Characteristics of studies included in the review.
Elsenbruch et al.,
2003 (19)
Hahn et al., 2005 (28)
Case-control study
Germany
Age-matched,
healthy women
30.1 9.8/24.4 5.3
Case-control study
Germany
Age-matched,
healthy women
31.0 9.3/24.0 5.3
Case-control study
Poland
Age-matched,
healthy women
24.6 3.8/22.1 2.9
Case-control study
China
Age-matched,
healthy women
24.57 3.91/21.08 2.15
Case-control study
China
Age-matched,
healthy women
N/A
12 5/3 2
2.7 0.9/1.1 0.6
2.7 1.2/1.3 0.6
1990 NIH
9.2 5.8/3.0 2.0
2.7 0.9/1.3 0.6
2.7 1.2/1.3 0.6
1990 NIH
N/A
N/A
N/A
2003 Rotterdam
N/A
N/A
N/A
2003 Rotterdam
Questionnaires
SF-36, SCL-90-R, FLZ
SF-36, SCL-90-R, VASs
12.7 6.1/2.7 2.1
N/A
N/A
PSE and 2003
Rotterdam
SF-36, ISS
SF-36, SCL-90-R,
LSIA, VASs
SF-36, SAS, SDS
SF-36 scores
(PCOS/control)
1 Physical function
2 Physical role function
3 Body pain
4 General health
5 Vitality
6 Social function
7 Emotional role function
8 Mental health
Total
Design of study
N/A
71 37/90 21
73 30/85 26
N/A
43 20/60 20
66 30/80 27
49 44/87 27
53 20/70 18
N/A
Cross-sectional
81 21/88 20
76 32/90 21
74 28/85 26
62 20/62 18
43 20/60 20
67 24/80 27
62 40/87 27
57 20/70 19
N/A
Cross-sectional
89.9 11.1/93.7 8.1
73.5 30.8/87.5 22.6
64.8 25.1/72.6 19.8
46.3 15.9/60.1 18.9
57.3 16.4/71.2 17.7
70.6 21.5/82.6 17.8
67.7 28.6/5.8 11.4
57.5 17.9/69.9 15.1
N/A
Cross-sectional
82.41 11.41/90.90 5.41
N/A
N/A
50.37 16.91/70.61 11.97
58.22 15.15/77.20 8.87
N/A
N/A
60.51 14.70/77.76 10.48
N/A
Cross-sectional
80 11/83 11
78 13/81 10
76 12/77 19
58 13/69 19
51 17/62 11
69 10/86 12
63 19/84 15
58 14/69 14
533 52/611 62
Cross-sectional
Study type
Location
Control
BMI (kg/m2)
(PCOS/control)
FG score
Testosterone (nmol/L)
LH/FSH ratio
PCOS diagnostic criteria
Drosdzol et al.,
2007 (20)
Wang et al.,
2007 (56)
Wang et al.,
2009 (57)
Vol. 96, No. 2, August 2011
Note: Values are presented as means SD, unless otherwise indicated. FG ¼ Ferriman-Gallwey; FLZ ¼ fragebogen zur lebenszufriedenheit; ISS ¼ index of sexual satisfaction; LSIA ¼ life satisfaction index A; N/A ¼
not available; NIH ¼ national institutes of health; PSE ¼ polish society of endocrinology; SAS ¼ self-rating anxiety scale; SCL-90-R ¼ symptom checklist 90; SDS ¼ self-rating depression scale; VASs ¼ visual
analogue scales.
Li. HRQoL in women with PCOS. Fertil Steril 2011.
FIGURE 2
FIGURE 2 Continued
Meta-analysis of studies on the HRQoL of women with PCOS.
Forest plots for MDs of all dimensions of SF-36. (A) Pooled data
on the physical function dimension showed lower values
(P¼.0005) in women with PCOS than healthy controls, without
significant among-study heterogeneity (P¼.05). (B) Pooled data
on the physical role function dimension showed lower values
(P<.0001) in women with PCOS than healthy controls, with
significant among-study heterogeneity (P¼.003). (C) Pooled
data on the body pain dimension showed lower values (P¼.01) in
women with PCOS than healthy controls, without significant
among-study heterogeneity (P¼.08). (D) Pooled data on the
general health dimension showed lower values (P¼.007) in
women with PCOS than healthy controls, but there was
significant among-study heterogeneity (P<.00001). (E) Pooled
data on the vitality dimension showed lower values (P<.00001)
in women with PCOS than healthy controls, without significant
among-study heterogeneity (P¼.07). (F) Pooled data on the
social function dimension showed lower values (P<.00001) in
women with PCOS than healthy controls, without significant
among-study heterogeneity (P¼.59). (G) Pooled data on the
emotional role function dimension showed lower values
(P<.00001) in women with PCOS than healthy controls, without
significant among-study heterogeneity (P¼.1). (H) Pooled data
on the mental health dimension showed lower values
(P<.00001) in women with PCOS than healthy controls, without
significant among-study heterogeneity (P¼.23).
studies, potential publication bias was not assessed using a funnel
plot or other corrective analytical methods (58). Overall there was
a mean Newcastle-Ottawa scale score of 5.6 out of 9 (range, 5–6).
Meta-Analysis
A meta-analysis of 5 studies (19, 20, 28, 56, 57) that used SF-36 was
performed. Unfortunately, we could not obtain scores from all dimensions. Included studies reported data on 708 women (423 with
PCOS and 285 healthy controls), and the number of subjects included in these studies ranged from 90 to 211. In only 1 of the 5 studies was the total score of SF-36 given (7). Therefore, data from each
dimension of SF-36 were calculated in the meta-analysis (Table 1).
Dimensions Analysis
Physical function Four studies (20, 28, 56, 57) compared scores on
the physical function dimension in women with PCOS and controls.
Women with PCOS had significantly lower values (MD, 5.46;
95% CI, 8.52, 2.41; P¼.0005), without heterogeneity among
studies (P¼.05) (Fig. 2A).
Li. HRQoL in women with PCOS. Fertil Steril 2011.
Risk of Bias in Included Studies
No study reported incomplete outcome data; therefore, there is high
risk of selective reporting bias. One study (19) reported that the proportional difference between women with PCOS and controls of an
unfulfilled wish to conceive a child was likely to be related to a selective bias. The protocols of included studies were unavailable, and detailed information could not be obtained from primary authors. The
outcomes of these 5 included studies might have been influenced by
selective reporting bias. Because there were fewer than 10 included
Fertility and Sterility
Physical role function Four studies (19, 20, 28, 57) compared
scores on the physical role function dimension in women with
PCOS and controls. Women with PCOS had significantly lower
values (MD, 5.76; 95% CI, 8.49, 3.03; P<.0001), with
heterogeneity among studies (P¼.003) and I2 ¼ 78% (Fig. 2B).
Body pain Four studies (19, 20, 28, 57) compared scores on the
body pain dimension in women with PCOS and controls. Women
with PCOS had significantly lower values (MD, 4.55; 95% CI,
7.99, 1.11; P¼.01), without heterogeneity among studies
(P¼.08) (Fig. 2C).
General health Four studies (20, 28, 56, 57) compared scores on the
general health dimension in women with PCOS and controls.
455
Women with PCOS had significantly lower values (MD, 11.34;
95% CI, 19.53, 3.15; P¼.007), but there was significant
among-study heterogeneity (P<.00001) and I2 ¼ 89% (Fig. 2D).
Vitality Five studies (19, 20, 28, 56, 57) compared scores on the
vitality dimension in women with PCOS and controls. Women
with PCOS had significantly lower values (MD, 15.14; 95% CI,
17.43, 12.84; P<.00001), with heterogeneity among studies
(P¼.07) (Fig. 2E).
Social function Four studies (19, 20, 28, 57) compared scores on the
social function dimension in women with PCOS and controls.
Women with PCOS had significantly lower values (MD, 15.95;
95% CI, 18.57, 13.33; P<.00001), and there was no
significant heterogeneity among studies (P¼.59) (Fig. 2F).
Emotional role function Four studies (19, 20, 28, 57) compared
scores on the emotional role function dimension in women with
PCOS and controls. Women with PCOS had significantly lower
values (MD, 23.86; 95% CI, 27.51, 20.21; P<.00001),
without heterogeneity among studies (P¼.1) (Fig. 2G).
Mental health Five studies (19, 20, 28, 56, 57) compared scores on
the mental health function dimension in women with PCOS and
controls. Women with PCOS had significantly lower values (MD,
13.83; 95% CI, 16.13, 11.53; P<.00001), without amongstudy heterogeneity (P¼.23) (Fig. 2H).
DISCUSSION
The present systematic review has demonstrated that women with
PCOS have lower HRQoL than women without the disorder. The
meta-analysis was conducted to show for the first time that women
with PCOS scored lower in each dimensions of SF-36, particularly
in the emotional role function. The meta-analysis included only
studies with age-matched controls because our objective was to
compare patients with PCOS with age-matched women. Studies
that used population normative data (23, 48, 49), patients with
other diseases (32, 47), or different ethnic populations (33, 35) as
controls were excluded from this meta-analysis, as were studies
without controls (34).
The high statistical heterogeneity of the physical role function
(I2 ¼ 78%) and general health (I2 ¼ 89%) dimensions may represent
substantial or considerable heterogeneity in the included studies,
which might decrease the generalizability of the results regarding
HRQoL for women with PCOS. These dimension outcomes should
be explored in future studies.
PCOS is a heterogeneous disorder, and its main symptoms are infertility, menstrual dysfunction, hirsutism, and obesity—all of which may
cause physical dysfunction and psychosocial stress. BMI would be
a significant confounder in the majority of the studies given the BMI
differences between patients and controls. However, it has been reported that not only overall anxiety symptom burden but also several
individual anxiety symptoms distinguished women with PCOS from
a control group matched for age, body weight, and BMI (59). In the
study by Coffey et al. (47), the psychologic dimension was more affected than the physical dimension as measured with SF-36. Jones
456
Li et al.
HRQoL in women with PCOS
et al. (34) found that the ‘‘role limitation-emotional’’ was the poorest
area of health, with mean scores of 50.4 on the SF-36 questionnaire,
which had the greatest negative impact on HRQoL in women with
PCOS. Our systematic review confirmed these conclusions and
extended our evidence based on the meta-analysis.
In previous studies, PCOS was associated with decreased QoL
and self-rated mental symptoms (19, 28). In one study (11), PCOS
was also linked to psychiatric syndromes as verified by structured
clinical assessments. Thus, clinicians should be aware that women
with PCOS are at high risk for common affective and anxiety disorders, as well as suicide attempts. Elsenbruch et al. (60) found an interesting phenomenon—that having a partner who supports the wish
for a child constitutes a protective factor and improves the emotional
well-being of patients. So they argued that it is important to address
not only the risk factors (e.g., obesity and hirsutism) but also protective factors, such as effective coping strategies (e.g., the ability to
have a healthy relationship despite the clinical symptoms of PCOS).
Generic instruments are designed to gauge HRQoL over a broad
spectrum of diseases and thus may not be sensitive enough to measure
HRQoL in specific illnesses (61). For example, in the study of Coffey
et al. (47), controlling for BMI abolished differences in all domains of
SF-36, which may suggest that women of normal weight with PCOS
have normal HRQoL. However, the differences measured by an
HRQoL questionnaire for women with PCOS (PCOSQ) remained
even after adjustment for BMI. Actually, even normal-weight women
with PCOS felt that they had problems with their weight.
Disease-specific instruments could more directly address the specific problems of women with PCOS (e.g., weight, body hair, infertility) who are significantly affected on the PCOSQ, which would not
be identified by a generic questionnaire (i.e., SF-36) because there
are no items pertaining to these dimensions. On the contrary, the findings cannot be compared with those of samples affected by other diseases and their healthy controls, which precludes an assessment of
the relative impact of the specific problems. The only PCOSspecific instrument currently available to measure HRQoL, PCOSQ,
appears to be reliable and valid. The sensitivity of the instrument has
not been confirmed, and more work is needed to confirm this
property of the questionnaire in different countries and ethnicities.
Moreira et al. (62) thought that previous research on PCOS conducted within a medical or psychiatric framework had failed to explore women’s own experience, such as impaired female identity
(51), and believed that a nonspecific instrument could not correctly
evaluate the psychologic impact of the disease. They suggested that
qualitative approaches be incorporated to gain an adequate understanding of the psychosocial impact of PCOS. Studies combining
quantitative and qualitative methods may reveal complementary
results.
In conclusion, this review demonstrated that PCOS has a significant negative impact on HRQoL, especially on the emotional role
function domain. Considering the insufficient evidence, this conclusion should be interpreted with caution. PCOS affects women both
psychologically and physically according to the SF-36. Welldesigned and well-conducted studies with expanded sample sizes
on the HRQoL of women with PCOS should be conducted in different countries and ethnicities.
Vol. 96, No. 2, August 2011
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