{"paper_id":"89a0181e-cec0-490c-b64f-9a1f2b949001","body_text":"Journal of Psychosomatic Obstetrics & Gynecology\nISSN: 0167-482X (Print) 1743-8942 (Online) Journal homepage: www.tandfonline.com/journals/ipob20\nMental illness and sleep disorders among women\nwith gynecological problems\nRay M. Merrill & Dajeong Song\nTo cite this article: Ray M. Merrill & Dajeong Song (2024) Mental illness and sleep disorders\namong women with gynecological problems, Journal of Psychosomatic Obstetrics &\nGynecology, 45:1, 2354330, DOI: 10.1080/0167482X.2024.2354330\nTo link to this article:  https://doi.org/10.1080/0167482X.2024.2354330\n© 2024 The Author(s). Published by Informa\nUK Limited, trading as Taylor & Francis\nGroup\nPublished online: 01 Jun 2024.\nSubmit your article to this journal \nArticle views: 2721\nView related articles \nView Crossmark data\nFull Terms & Conditions of access and use can be found at\nhttps://www.tandfonline.com/action/journalInformation?journalCode=ipob20\n\nReseaR ch aR ticle\nJournal of Psychosomatic obstetrics & GynecoloGy\n2024, Vol. 45, no . 1, 2354330\nMental illness and sleep disorders among women with gynecological \nproblems\nRay M. Merrill and Dajeong s ong\nDepartment of Public health, c ollege of life s ciences, brigham young university, Provo, ut , usa\nABSTRACT\nt his retrospective cohort study identifies differences between rates of selected mental illnesses \nand sleep disorders according to eight gynecological problems. a nalyses utilize medical claims \ndata for adult employees of a large corporation during 2017–2021. Women with a gynecological \nproblem (most notably pain, endometriosis, pelvic inflammation and bleeding) are significantly \nmore likely to experience mental illness. s everal gynecological problems are also significantly \nassociated with sleep disorders. Women with a gynecological problem (vs. none) are 50% more \nlikely to have a mental health problem and 44% more likely to have a sleep disorder after \nadjusting for age, marital status, dependent children and year. t he largest differences between \nhigher (%) mental illness and sleep disorders appear for hyperplasia (6% vs. 45%), cancer (11% \nvs. 68%), pelvic inflammation (46% vs. 79%) and pain (79% vs. 43%), respectively. On the other \nhand, the rate of having one or more gynecological problems ranges from 7.1% for women with \nno mental illness or sleep disorder to 20.6% for women with schizophrenia. Understanding the \nassociation between gynecological problems, mental illness and sleep disorders can help clinicians \nmore effectively identify and treat patients.\nIntroduction\nGynecological problems encompass a wide range of \nconditions, such as vulvodynia, hyperplasia and pelvic \ninflammation. t hese and other gynecological problems \nadversely affect women’s psychological health and \nquality of sleep [ 1,2]. i n turn, mental illness and sleep \nquality may also adversely affect gynecological prob -\nlems [ 3,4].\nin a recent systematic review of 50 studies and \nmeta-analysis of 31 studies, diagnosis of gynecological \nproblems was associated with a 2- to 3-fold increased \nodds of having a mental illness [ 5]. s tudies identified in \nthis review and meta-analysis tended to assess the \neffects of pelvic pain and polycystic ovary syndrome on \nanxiety, depression and bipolar disorder. s tudies that go \nbeyond those identified in the review involve endome -\ntriosis, uterine bleeding, prolapse and uterine fibroids.\na population-based study in s weden found that \nendometriosis was associated with stress, anxiety, \ndepression and aDhD [ 6]. a study of 96 patients with \nuterine bleeding and 94 controls found that uterine \nbleeding was positively associated with anxiety, \ndepression and obsessive-compulsive disorder (OcD) \n[7]. i n a case-control study involving 75 cases with pel -\nvic organ prolapse and 65 controls found that cases \nwere five times more likely to have depressive symp -\ntoms [ 8]. i n a study of 313,754 women with uterine \nfibroids and 627,539 controls, women with uterine \nfibroids had significantly higher rates of anxiety, \ndepression and self-directed violence, especially among \nthose women who experienced pain symptoms [ 9].\na lthough few studies consider the possible causal \ndirection of mental illness on gynecological problems, \na study of 240 case-control pairs of women found that \nthe odds of vulvodynia were four times greater in \nthose with antecedent mood or anxiety compared to \nwomen without [ 3]. clinical studies have also shown \nthat women with endometriosis have increased stress, \nbut also that chronic stress can be a cause of endome -\ntriosis [ 4].\n© 2024 t he a uthor(s). Published by i nforma uK limited, trading as taylor & f rancis Group\nCONTACT r ay m. m errill  r ay_merrill@byu.edu  Gerontology Program, brigham young university, 2063 life s cience building, Provo, ut 84604, usa\nhttps://doi.org/10.1080/0167482X.2024.2354330\nt his is an o pen a ccess article distributed under the terms of the c reative c ommons a ttribution license ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted \nuse, distribution, and reproduction in any medium, provided the original work is properly cited. t he terms on which this article has been published allow the posting of the \na ccepted m anuscript in a repository by the author(s) or with their consent.\nARTICLE HISTORY\nReceived 6 March 2024\nRevised 25 a pril 2024\na ccepted 5 May 2024\nKEYWORDS\nMedical claims; mental \nillness; rates; sleep \ndisorder; women\n\n2 R. M. MeRRill aND D. sONG\nin a study of 838 women aged 31–54  years enrolled \nin a study of pelvic problems, 33.7% reported poor \nsleep quality and 46.8% reported short sleep duration \n[2]. Women with higher pelvic problem scores also \nwere more likely to experience poor sleep. in a \ncase-control study involving 157 women chronic pelvic \npain had significantly poorer sleep quality [ 10]. i n a \nsystematic review of 22 papers, insomnia increased \n14–60% in ovarian cancer patients [ 11]. i nsomnia was \nassociated with emotional distress, anxiety and depres -\nsion. i n an age-matched case-control study of 145 \nwomen with endometriosis and 145 controls, poor \nsleep quality was significantly greater in the women \nwith endometriosis (64.8% vs. 15.1%) [ 12]. i n a study \nof 156 infertile women, endometriosis was associated \nwith lower levels of sleep quality [ 13]. a \ncommunity-based sample of 579 premenopausal \nwomen found that short sleep duration and poor \nsleep quality were associated with heavier bleeding \nand menstrual cycle irregularity [ 14].\nt he mental illness outcome variables in these stud -\nies tend to be anxiety and depression, and the sleep \ndisorder outcome variable tends to be insomnia. Other \nmental illnesses and sleep disorders may also be of \ninterest. Further, studies have not compared the asso -\nciations for a more comprehensive list of gynecological \nproblems, mental illnesses and sleep disorders. Finally, \nthe association between gynecological problems and \nmental illnesses may change after adjusting for sleep \ndisorders. likewise, the association between gyneco -\nlogical problems and sleep disorders may change after \nadjusting for mental illnesses.\nt he purpose of this study was (1) to identify the \nrate of eight gynecological problems in an adult \nemployee population of women; (2) compare rates of \nselected mental illnesses and sleep disorders accord -\ning to each gynecological problem, adjusting for age, \nmarital status, dependent children and year; and (3) \ncompare rates of having one or more gynecological \nproblems according to each mental illness and sleep \ndisorder.\nMaterials and methods\nStudy population\nt he current study involves employees of the church of \nJesus christ of latter-day s aints (lDs) receiving health \ninsurance from the Deseret Mutual Benefit administrator \n(DMBa ). t he DMBa is a subsidiary of the Deseret \nManagement c orporation (s alt lake c ity, Ut ), the \nglobal operating company over the church’s for-profit \nentities. i t has been in operation since 1970 to provide \nhealth insurance and retirement income to employees \nand their families. t he study utilizes electronic claims \ndata for the years 2017–2021. a “claim” is a notification \nto DMBa requesting a medical benefit payment. We \ndo not include pharmaceutical claims in this paper. \nGeographic areas represented by enrollees included \nUtah (74%), idaho (9%), Pacific states (9%) and other \na merican states (8%).\neach year the cohort consisted of approximately \n27% employees, 21% spouses, 48% dependent chil -\ndren and 4% other (e.g. married child, stepchild and \ndisabled dependent). a mong employees, 34% worked \nin the church education system, seminaries and insti -\ntutes; 31% as manual laborers; 10% in other compa -\nnies; 6% were retired; and the remaining 19% worked \nin other capacities. We do not include retirees in this \nstudy. employee retention was about 92% (80% in \nages 18–29, 95% in ages 30–64, and 76% in ages \n65  years or older) from year to year. t he number of \nemployees insured through DMBa dropped for individ -\nuals aged 65  years and older as they became eligible \nfor Medicare.\nData collection\nt he study involved the following number of female \nlDs employees insured through DMBa: 6579 in 2017, \n6806 in 2018, 6814 in 2019, 6512 in 2020, and 6652 in \n2021. t hese data represent eligibility data linked to \nautomated medical claims records using a common \nidentifying number. Following the linkage of the data \nand before analysis, the database was de-identified \naccording to health i nsurance Portability and \na ccountability a ct (hiP aa ) guidelines. t he authors’ \ninstitutional review board approved the study.\nclassification of mental illness, sleep disorders and \ngynecological problems was based on the international \nclassification of Diseases, tenth Revision, clinical \nModification (icD-10- cM) [ 15].\nt he Diagnostic and s tatistical Manual of Mental \nDisorders (DsM) helps psychiatrists, physicians, clinical \npsychologists and other health professionals diagnose \nbehavioral health issues [ 16]. t he DsM diagnostic crite -\nria serve as a guide in determining billing codes \naccording to the icD-10- cM. c odes used to classify \nmental illnesses are F20–F29 for schizophrenia, delu -\nsional and other non-mood-psychotic disorders (here -\nafter called schizophrenia); F31 for bipolar disorder; \nF32–F33 for depression; F40–F41 for anxiety; F42 for \nOcD; F43 for stress; and F90 for attention deficit hyper -\nactivity disorder ( aDhD). c odes used to classify sleep \ndisorders are G470 (insomnia), G471 (hypersomnia), \nG473 (sleep apnea), G472 (circadian rhythm sleep \n\nJOURNal OF  PsychOsOM atic OBstetRics & Gy Nec Ol OGy 3\ndisorders), G474 (narcolepsy and cataplexy), G475 \n(parasomnia), G476 (sleep-related movement disor -\nders), G478 (other sleep disorders) and G479 (unspeci -\nfied sleep disorders). c odes used for classifying female \ngynecological problems include N80 for endometriosis, \nN81 for prolapse, N85 for endometrial hyperplasia, D25 \nfor leiomyoma of the uterus (fibroids), c51– c58 for \ncancer, N93 for abnormal uterine and vaginal bleeding, \nN70–N77 for inflammatory diseases of the female pel -\nvic organs and N94 for pain and other conditions asso -\nciated with the female genital organs and \nmenstrual cycle.\nRates consist of the number of enrollees filing one \nor more claims for each condition divided by the num -\nber of enrollees. i f multiple claims are filed by an \nemployee in a year for a specific condition, it is only \ncounted once in the numerator of the rate calculation. \nhowever, an individual may contribute to more than \none type of mental illness, sleep disorder or gyneco -\nlogical problem each year. t he level of any mental ill -\nness in our female employee population is very similar \nto the prevalence from U.s. National c ross-sectional \nsurvey Data. For example, the prevalence of women \nwith a mental illness (icD-10- cM codes F0–F9) in 2017 \nthrough 2021 was 21.3%, 22.4%, 24.1%, 25.8% and \n26.8%, respectively. t he prevalence identified in U.s. \nsurvey data for women in the corresponding years was \n22.3%, 22.8%, 24.5%, 25.8% and 27.2, respectively [ 17].\nOther variables considered in this study are age, \nmarital status, dependent children status and year. \nclassifications for these variables appear in table 1 .\nStatistical techniques\nNumbers, percentages, means, standard deviations and \nrates described the variables. We assessed whether the \nlevels of mental illness, sleep disorders and gynecolog -\nical problems varied across the levels of other vari -\nables using the chi-square test. We compared rates \nusing rate ratios, adjusted for age, marital status, \ndependent children status and year. t he significance of \nthe adjusted rate ratios was determined using the \nc ochran–Mantel–haenszel test. s tatistical significance \nwas based on two-sided tests and the .05 level. We \nconducted our statistical analyses using statistical \na nalysis s ystem (sas) software, version 9.4 (sas \ninstitute inc., c ary, Nc, 2014).\nResults\nMental illness affects 24.1%, sleep disorders 9.1% and \ngynecological problems 8.4% of women. a ges range \nfrom 18 to 64 ( M  =  45.9, sD = 12.6). a bout 55.8% of \nemployees are married and 41.3% have dependent \nchildren ( table 1 ).\nTable 1.  m ental illness, sleep disorders or female gynecological problems according to selected variables among Dmba employ -\nees, 2017–2021.\nmental illness sleep disorder f emale gynecological problem\nno. % % p Value % p Value % p Value\nage\n 18–49 18,809 56.38 26.04 <.0001 5.33 <.0001 10.17 <.0001\n 50–64 14,554 43.62 21.57 14.08 6.07\nmarried\n no 14,754 44.22 26.14 <.0001 8.85 .0983 7.49 <.0001\n yes 18,609 55.78 22.46 9.38 9.09\nDependent children\n no 19,584 58.7 24.24 .4461 9.87 <.0001 8.19 .1290\n yes 13,779 41.3 23.88 8.11 8.66\nyear\n 2017 6,579 19.72 21.34 <.0001 8.53 .0815 8.22 .2677\n 2018 6,806 20.40 22.42 8.68 8.54\n 2019 6,814 20.42 24.13 9.38 8.88\n 2020 6,512 19.52 25.77 9.46 7.83\n 2021 6,652 19.94 26.83 9.68 8.42\nmental illness\n no 25,326 75.91 6.53 <.0001 7.28 <.0001\n yes 8,037 24.09 17.39 11.86\nsleep disorder\n no 30,312 90.86 21.90 <.0001 8.14 <.0001\n yes 3,051 9.14 45.82 10.78\nf emale genial problem\n no 30,566 91.62 23.18 <.0001 8.91 <.0001\n yes 2797 8.38 34.07 11.76\nt he p value is based on the chi-square test of independence. icD-10- cm codes: f0–f9 (mental illness), G47 (sleep disorders), n80, n81, n85, D25, c51–\nc58, n93, n70–n77 and n94 (female gynecological problems).\n\n4 R. M. MeRRill aND D. sONG\nAge\nMean age is significantly lower for those women with \nmental illness (45.1 vs. 46.2, p  <  .0001), higher for those \nwomen with a sleep disorder (52.8 vs. 45.2, p  <  .0001) \nand lower for those women with a gynecological prob -\nlem (43.4 vs. 46.2, p  <  .0001). sleep disorders increase \nwith age. Gynecological problems are greatest in \nyounger aged women. Rates in younger women (ages \n18–49 vs. 50–64) are 195.3% ( p  <  .0001) higher for \nendometriosis, 27.0% ( p  =  .0079) higher for fibroids, \n153.6% (p < .0001) higher for bleeding, 54.4% ( p < .0001) \nhigher for pelvic inflammation, and 419.4% ( p  <  .0001) \nhigher for pain. t hey are 66.4% ( p  <  .0001) lower for \nprolapse and 81.7% ( p  <  .0001) lower for cancer. t here \nis not a significant difference for hyperplasia.\nMarital status\nMarriage is associated with lower rates of mental ill -\nness but higher rates of gynecological problems. Rates \nof gynecological problems in married (vs. single) \nwomen are 88.2% ( p  <  .0001) higher for prolapse, \n71.2% ( p  <  .0001) higher for hyperplasia, 25.9% \n(p  =  .0102) higher for fibroids, 40.8% ( p  <  .0001) higher \nfor bleeding, 21.1% ( p < .0001) higher for pelvic inflam -\nmation, and 22.3% ( p  =  .0037) higher for pain. t hey \nare 42.5% ( p  =  .0005) lower for cancer. t here is not a \nsignificant difference for endometriosis.\nDependent children\nhaving dependent children is not associated with rates \nof mental illness or gynecological problems but is \nassociated with lower rates of sleep disorders. t here is \nno difference in the rates of sleep disorders between \nwomen with children and those without children \nexcept for sleep apnea (7.36% with no children vs. \n5.58% with children, p  <  .0001). Rates of mental illness \ntend to increase with calendar year.\nMental illness and sleep disorders by \ngynecological problems\nt he most common types of female gynecological \nproblems are pain, pelvic inflammation and bleeding \n(table 2 ). Gynecological problems tend to be associ -\nated with higher levels of both mental illness and \nsleep disorders, mental illness only, or sleep disorder \nonly ( Figure 1). c ompared with no gynecological prob -\nlem, women are 48.2% more likely to have both men -\ntal and sleep disorders, 41.9% more likely to have \nmental illness only, and 14.0% more likely to have a \nsleep disorder only. Pain has the largest association \nwith mental illness and cancer has the largest associa -\ntion with sleep disorder.\nRates of selected types of mental illness and sleep \ndisorders are compared between having (vs. not hav -\ning) a gynecological problem, adjusted for age, marital \nstatus, dependent children and year ( table 3 ). Women \nwith a gynecological problem are 43.8% more likely to \nhave a mental illness and 50.0% more likely to have a \nsleep disorder. t he rate of mental illness ranges from \n6% higher for women with fibroids to 79% higher for \nwomen with pain. similarly, the rate of sleep disorders \nranges from 21% higher for women with prolapse to \n74% higher for women with pelvic inflammation. \nstress, anxiety, depression, schizophrenia, insomnia, \nhypersomnia, sleep apnea and other sleep disorders \nare significantly greater for women with a gynecologi -\ncal problem. endometriosis, bleeding, pelvic inflamma -\ntion and pain are the only gynecological problems \nTable 2. m ental illness and sleep disorders according to gynecological problems among Dmba employees, 2017–2021.\nstress a nxiety Depression aDhD bipolar ocD schizophrenia insomnia hypersomnia\nsleep \napnea\no ther \nsleep \ndisorder\nno. % % % % % % % % % % % %\na ll employees 33,363 100 3.51 13.31 12.14 1.66 0.70 0.35 0.10 2.63 0.77 6.62 0.80\nendometriosis 236 0.71 8.05 20.76 15.25 2.12 0.85 0.85 0.42 2.97 0.42 6.78 2.12\nProlapse 253 0.76 4.35 14.23 11.46 1.58 0.79 0.79 – 3.95 1.98 11.46 1.19\nhyperplasia 297 0.89 3.37 14.48 12.12 1.01 0.67 – 0.34 2.02 0.34 12.12 1.68\nf ibroids 515 1.54 4.85 14.56 13.40 1.94 – 0.19 0.39 3.50 1.17 8.74 1.94\nc ancer 157 0.47 1.91 13.30 12.10 – – – 0.64 2.55 1.27 18.47 0.64\nbleeding 680 2.04 5.00 17.50 18.68 2.50 0.59 0.44 0.44 2.65 1.47 9.26 1.91\nPelvic \ninflammation\n728 2.18 6.73 19.37 17.72 2.88 0.55 0.41 0.14 4.26 1.24 9.89 1.65\nPain 849 2.54 7.77 26.97 22.26 2.36 0.82 0.71 0.24 2.83 1.30 4.36 1.65\na ny \ngynecological \nproblems\n2797 8.38 5.97 19.31 17.27 1.97 0.64 0.54 0.25 3.04 1.18 8.40 1.54\naDhD: attention deficit hyperactivity disorder; ocD: obsessive compulsive disorder; (–) no cell counts.\no ther sleep disorders refer to circadian rhythms sleep disorders, narcolepsy and cataplexy, parasomnia, sleep related movement disorders, other sleep \ndisorders and unspecified sleep disorders.\n\nJOURNal OF  PsychOsOM atic OBstetRics & Gy Nec Ol OGy 5\nlinked to mental illnesses. t he rate ratios for schizo -\nphrenia are the largest, but because of small numbers \ntend to not be statistically significant.\nRates of mental illness and sleep disorders accord -\ning to whether the selected gynecological problems \nexist appear in Figure 2 . Women with hyperplasia, \nFigure 1.  r ate of mental illness and/or sleep disorder according to status of gynecological problem.\nTable 3. r ates of mental and sleep disorders according to gynecological problems among Dmba employees, 2017–2021.\nstress a nxiety Depression aDhD bipolar ocD schizophrenia\na ny \nmental \nillness insomnia hypersomnia\nsleep \napnea\no ther \nsleep \ndisorderb\na ny \nsleep \ndisorder\nr ate ratio a\nendometriosis 2.02 1.43 1.18 1.24 1.21 2.05 5.34 1.51 1.26 0.57 1.28 2.70 1.42\nProlapse 1.43 1.23 1.00 1.10 1.27 3.73 – 1.13 1.17 2.14 1.27 1.14 1.21\nhyperplasia 0.92 1.10 1.01 0.69 0.96 – 4.59 1.06 0.72 0.39 1.74 1.85 1.45\nf ibroids 1.29 1.08 1.07 1.30 – 0.59 4.16 1.14 1.25 1.42 1.27 2.16 1.31\nc ancer 0.56 1.22 0.98 – – – 4.46 1.11 0.70 1.30 1.85 0.76 1.68\nbleeding 1.30 1.23 1.50 1.45 0.83 1.16 6.79 1.28 1.13 2.02 1.77 2.52 1.60\nPelvic \ninflammation\n1.89 1.44 1.47 1.79 0.80 1.12 1.65 1.46 1.83 1.67 1.74 2.18 1.74\nPain 2.01 1.89 1.84 1.31 1.11 1.52 3.63 1.79 1.54 2.15 1.07 2.67 1.43\na ny \ngynecological \nproblems\n1.72 1.46 1.46 1.19 0.90 1.45 3.62 1.44 1.29 1.67 1.51 2.18 1.50\naDhD: attention deficit hyperactivity disorder; ocD: obsessive compulsive disorder; (–) no cell counts.\nshaded cells are statistically significant at the .05 level.\naa djusted for age, marital status, dependent children and year.\nbo ther sleep disorders refer to circadian rhythms sleep disorders, narcolepsy and cataplexy, parasomnia, sleep related movement disorders, other sleep \ndisorders and unspecified sleep disorders.\n\n6 R. M. MeRRill aND D. sONG\nFigure 2.  r ates of mental and sleep disorders according to female gynecological problems. r ate ratios adjusted for age, marital \nstatus, dependent children and year.\nFigure 3.  r ate of having a gynecological problem according to types of mental illnesses and sleep disorders.\n\nJOURNal OF  PsychOsOM atic OBstetRics & Gy Nec Ol OGy 7\ncancer, bleeding and pelvic inflammation have higher \nrates of sleep disorders than mental illness. For exam -\nple, women experiencing bleeding are 27.7% more \nlikely to have mental illness and 60.0% more likely to \nhave sleep disorders. On the other hand, women expe -\nriencing pain associated with female genital organs \nand menstrual cycle have higher rates of mental illness \nthan sleep disorders. For example, women experienc -\ning pain are 78.7% more likely to have mental illness \nand 43.1% more likely to have sleep disorders.\nWe now consider the rate of one or more gyneco -\nlogical problems in women with a mental illness or \nsleep disorder ( Figure 3 ). t he rate of gynecological \nproblems is greater for each of the mental illnesses \nand sleep disorders compared with no mental illness \nor sleep disorder. Women with schizophrenia have the \nhighest rate of gynecological problems.\nDiscussion\nt his study identified the rate of eight gynecological \nproblems in an adult employee population. i t compared \nrates of selected mental illnesses and sleep disorders \naccording to each gynecological problem, adjusting for \nage, marital status, dependent children and year. Rates \nof having one or more gynecological problems accord -\ning to each mental illness and sleep disorder were also \npresented. an important strength of this study is its size \nand that several gynecological problems are evaluated \nsimulations, according to their relationship with mental \nillness only, sleep disorders only, and a combination of \nboth mental illness and sleep disorders.\na ge, marital status and dependent children show \nimportant relationships with mental health, sleep and \ngynecological conditions. t he rate of mental illness is \ngreatest in the ages 30–49. t his is consistent with \nmental health services received in the past year \namong U.s. adults with any mental illness [ 18]. t he \nrate of sleep disorders increases with age, as consis -\ntent with other research [ 19]. t his increase with age \nmay be because older age is positively associated \nwith factors that negatively affect sleep. Rates of \ngynecological problems are greatest in the ages \n30–49  years and lowest in the ages 50–64  years. \na lthough this result is for all gynecological problems \ncombined, a separate analysis showed that the age \npattern is unique to the given gynecological problems \n(data not shown). For example, prolapse and cancer \nincrease with age, and bleeding and inflammation \ndecrease with age.\nMarriage is associated with a lower rate of mental \nillness, as found in other studies [ 20–22]. i n contrast, \nmarriage is associated with higher rates of \ngynecological problems like prolapse, hyperplasia, \nfibroids, bleeding, pelvic inflammation and pain. h igher \nrates in married women continue after adjusting for \nage, dependent children and year (data not shown). \nt his result may be because married women are more \nlikely to seek medical care for their gynecological \nproblems. Research has shown that marriage can \nencourage health-promoting behaviors such as health -\ncare utilization [ 23].\na lthough having dependent children is not associ -\nated with rates of mental illness or gynecological \nproblems, it is associated with lower rates of sleep dis -\norders. t his may be because women who have chil -\ndren are healthier in general and better health is \nassociated with lower rates of sleep disorders. For \nexample, women with obesity, type 2 diabetes, hyper -\ntension or cardiovascular disease have a higher risk of \nsleep disorders [ 24].\nt he most common gynecological problems involve \nbleeding, pelvic inflammation and pain. For these \ngynecological problems, as well as endometriosis and \nfibroids, rates are higher prior to menarche. Menstrual \ndisorders include abnormal uterine bleeding, fibroids, \nand severe physical and emotional discomfort (pain \nand cramping) prior to menstruation. Pelvic inflamma -\ntion usually occurs from sexually transmitted bacteria \nof one or more of the upper reproductive organs \n(uterus, fallopian tubes and ovaries), which may \ndevelop into chronic pelvic pain. c onsistent with our \nresults, pelvic organ prolapse is more common in \nolder women [ 25].\nRates of mental illness compared with rates of sleep \ndisorders according to the status of the gynecological \nproblems are significantly different for a few of the \ngynecological conditions. h yperplasia, cancer, bleeding \nand pelvic inflammation are more strongly associated \nwith sleep disorders (with sleep apnea significant for \neach condition), and pain is more strongly associated \nwith mental illness (primarily stress, anxiety and depres -\nsion). t he strong association between pelvic inflamma -\ntion and sleep disorders is consistent with previous \nresearch [2,10]. c ancer has the second strongest associa-\ntion with sleep disorders, primarily involving sleep apnea. \nt his result is consistent with a systematic review and \nmeta-analysis [26]. t his may be due to both having com -\nmon risk factors such as cigarette smoking and excessive \nweight, but also because a greater risk of cancer is \nlinked to oxygen deprivation and serious blood clots in \nthe veins caused by sleep apnea [ 27]. t he prevalence of \nanxiety, depression and substance use disorders is com -\nmon in people with chronic pain, and anxiety and \ndepression can lead to behaviors (e.g. cigarette smoking \nand substance abuse) that contribute to pain [ 28].\n\n8 R. M. MeRRill aND D. sONG\nendometriosis, bleeding, pelvic inflammation and \npain are the only gynecological problems significantly \nassociated with mental illnesses. Other studies have \nalso found these associations [ 5–7]. For example, in a \ncross-sectional study of 212 women with chronic pel -\nvic pain, higher pain severity was associated with \ngreater stress and anxiety [ 29]. i n a cross-sectional \nstudy of 100 women with chronic pelvic pain and 100 \nwomen without chronic pelvic pain, the prevalence of \nanxiety was 66% in the control group and 49% in the \ncontrols ( p  =  002) [ 30]. t he prevalence of depression \nwas 63% in the chronic pain group and 38% in con -\ntrols ( p  <  .01). however, other studies also found sig -\nnificant associations between prolapse, uterine fibroids \nand mental illness. a lthough we found that those with \nprolapse were 12.8% more likely to experience any \nmental illness and those with fibroids were 14.0% \nmore likely to experience mental illness, the insignifi -\ncant results may be due to small numbers.\nstress, anxiety and depression are most consistently \nassociated with gynecological problems. aDhD is not \nsignificantly associated with gynecological problems \noverall but is significantly associated with pelvic \ninflammation. Research has shown that inflammation \ncan negatively affect brain structure, resulting in neu -\nrodevelopmental disorders like aDhD [ 31]. a lthough a \npopulation-based study in sweden found that endo -\nmetriosis was associated with aDhD [ 6], we did not \nfind this result. t he large sample size in that study \nmay explain their significant findings.\nt he association between gynecological problems \nand schizophrenia is significant. Women with schizo -\nphrenia are most likely to have a gynecological prob -\nlem (see Figure 3 ). s tress and major dramatic life \nchanges can trigger schizophrenia. i t is possible that \nschizophrenia may be precipitated by female gyneco -\nlogical problems and associated stress and anxiety. \na ssociations for the individual gynecological sites and \nschizophrenia are larger than for the other mental ill -\nnesses, but small numbers limit finding statistical sig -\nnificance, except for bleeding (see table 3). t he positive \nassociation between gynecological problems and \nschizophrenia is consistent with previous research [ 32]. \nt he association between abnormal uterine bleeding \nand schizophrenia may be partly explained by \nsex-hormonal imbalance in schizophrenia patients, \nwhich is sometimes attributed to a hyperprolactinemia \neffect of antipsychotics [ 33].\nt he current study has certain limitations. Rates were \nbased on employees who filed healthcare claims. some \nless serious cases of mental illness and sleep disorders \nmay not have sought medical attention. c onsequently, \nthey would not be represented in the prevalence esti -\nmates. however, our overall estimated level of mental \nillness based on medical claims is almost the same as \nnational estimates from cross-sectional surveys (see \nthe “Data collection” section). large ranges reported in \nthe literature on sleep disorders among adult women \nmake it difficult to determine whether the current \nresults are noticeably underestimating the prevalence \nof sleep disorders for less serious cases. Nevertheless, \nwe do believe that the current study accurately reflects \nthe prevalence of mental illness and sleep disorders in \nchronic cases. i n addition, combinations of types of \ngynecological problems and mental illness or sleep \ndisorders sometimes involved small numbers, which \nlimited determination of statistical significance, espe -\ncially for schizophrenia. Further, the current study \nfocused on an employee population aged 18–64  years, \nprimarily from the Western United s tates. employees \nand younger people tend to be healthier than the \ngeneral population, so generalization of the results \nshould be done with caution. Finally, the current study \nis limited to identifying statistical associations and not \ncausal relationships.\nConclusions\nGynecological problems cover a range of conditions \nthat can significantly impact women’s mental and \nphysical health. Gynecological problems are associated \nwith higher rates of stress, anxiety, depression, schizo -\nphrenia, insomnia, hypersomnia, sleep apnea and \nother sleep disorders. Women with a gynecological \nproblem (vs. none) are 50% more likely to have a men -\ntal health problem and 44% more likely to have a \nsleep disorder, after adjusting for age, marital status, \ndependent children and year. On the other hand, the \nrate of mental illness or sleep disorders has higher \nrates of gynecological problems, especially in women \nwith schizophrenia (20.6%). Understanding the associ -\nation between gynecological problems, mental illness \nand sleep disorders can help clinicians more effectively \nidentify and treat patients.\nAcknowledgements\nt he authors wish to thank Glenn Barrett for preparing the \ndata files used in the current study.\nEthical approval\nt his study was performed in line with the principles of the \nDeclaration of helsinki. t he authors’ institutional review \nboard approved the study (iRB2021-157).\n\nJOURNal OF  PsychOsOM atic OBstetRics & Gy Nec Ol OGy 9\nConsent form\nNot applicable.\nDisclosure statement\nNo potential conflict of interest was reported by the \nauthor(s).\nFunding\nNo funding was received for this article.\nData availability statement\nt he datasets generated and/or analyzed in this study are \navailable from the corresponding author upon reasonable \nrequest.\nReferences\n [ 1] hope h, Pierce M, Johnstone eD, et  al. t he sexual and \nreproductive health of women with mental illness: a \nprimary care registry study. a rch Womens Ment health. \n2022;25(3):585–593. doi: 10.1007/s00737-022-01214-y\n [ 2] singh JK, l earman la, Nakagawa s, et  al. sleep prob -\nlems among women with noncancerous gynecologic \nconditions. 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