Assessment of Eating Disorders Among Patients with Polycystic Ovary Syndrome Presenting to a Specialty Hospital in Eastern India: A Cross-Sectional Study.

Background Mental health disorders accompanying polycystic ovary syndrome (PCOS) are important but underestimated aspects. There is paucity of literature (Indian) regarding the association of PCOS and eating disorders. Objectives were—(1) know the distribution of PCOS patients across sociodemographic variables—age, BMI and parity. (2) Know the distribution of PCOS patients according to menstrual history. (3) Know the relative frequency (percentage) of different eating disorders (binge eating disorder, bulimia nervosa and anorexia nervosa) in the study population. (4) Analyze association between eating disorders and PCOS in comparison with normal age-matched controls by eating disorder examination questionnaire (EDE-Q) scores.

This institution-based cross-sectional observational study included consecutive 50 diagnosed PCOS patients of age 16–40 years giving explicit consent & equal number of age-matched controls. Patients with other concomitant diagnosed gynecological disorders and pregnancy were excluded. Study variables were—(1) age, (2) BMI, (3) parity, (4) menstrual status, (5) eating disorders and (6) EDE-Q subscale scores and global score.

Mean age of PCOS patients is 26.56 ± 4.33 years. Majority of PCOS patients were overweight, nulliparous and oligomenorrheic with binge eating disorder (52%). Majority of control women were overweight, nulliparous and eumenorrheic without any eating disorder (88%). Independent t-test showed statistically significant differences between PCOS patients with eating disorder and non-PCOS control women with eating disorder in EDE-Q global score and eating concern, shape concern and weight concern subscale scores, but no significant difference was observed in restraint subscale score.

Statistically significant association found between PCOS and eating disorder across all domains except restraint domain. Therefore, it is important to raise awareness and provide education to women about disordered eating in PCOS. Formalized treatment guidelines, collaborative multidisciplinary effort and high degree of clinical suspicion are required in health professionals for timely diagnosis of both disorders to promote lifestyle management early on to prevent complications.

Binge eating disorder, Bulimia nervosa, Anorexia nervosa, Polycystic ovary syndrome

Originally described by Stein and Leventhal, Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in a woman of reproductive age-group [1]. A heterogeneous, multifactorial and polygenic condition characterized by menstrual disturbances (oligomenorrhea/amenorrhea), hyperandrogenism (hirsutism, acne), obesity and insulin resistance associated with enlarged polycystic ovaries without specific underlying diseases of the adrenal or pituitary glands [2–4]. The mental health disorders accompanying it, though important, are the underestimated aspects [4–6]. The relationship of the PCOS with mental health disorders is lesser known, but there have been reports suggesting that eating disorders (EDs) particularly binge eating symptomatology are found more often in women with PCOS than in general population along with other mental health illness like anxiety disorders and depressive disorders [1, 6, 7]. Complications of EDs include infertility, unplanned pregnancy, recurrent miscarriage and neonatal complications—all these lead to poor quality of life in PCOS women [8, 9]. The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V) delineates three EDs, viz., binge eating disorder, bulimia nervosa and anorexia nervosa as relevant to PCOS. In addition, avoidant/restrictive food intake disorder, pica, rumination disorder and other specified eating disorder are recognized [10]. Risk factors for EDs can be classified into two—general risk factors for mental health disorder (e.g., premorbid mental health disorder and disruptive life events) and those which increase the risk of dieting (e.g., critical comments by family about shape/weight, eating, and appearance) [2]. Studies have linked obesity, body fat distribution, insulin resistance and nutritional habits with the hormonal and metabolic profiles of PCOS and interventions like reducing weight and/or hyperinsulinemia either by diet alone or by a combination of diet and drugs improve hirsutism, ovulatory function, fertility and the hormonal and metabolic profiles of PCOS [2, 11], but these measures may lead to weight-related stigma and development of EDs or exacerbation of preexisting EDs [6]. Also dissatisfaction with self-appearance and emotional distress are often associated with PCOS, and both play very important role in pathogenesis of EDs [2]. Literature suggests binge eating disorder is more common in PCOS than bulimia nervosa and anorexia nervosa [2, 10]. Ninety percentage of EDs occur in women, mainly in teenagers and young women [1, 12]. For comprehensive treatment of PCOS, careful attention must be paid to its psychological symptomatology, and various studies advocate screening of PCOS women for abnormal eating behavior [2, 13, 14]. However, there is paucity of literature, particularly Indian study regarding the association of PCOS and EDs. Aim and Objectives The study aims to assess EDs among patients with PCOS presenting to our hospital, an industry-based specialty setup in eastern India, in a cross-sectional manner and to ascertain association between PCOS and ED. To accomplish this, specific objectives of the study are— To know the distribution of PCOS patients across sociodemographic & gynecological variables, viz., age, BMI and parity. To know the distribution of PCOS patients according to menstrual history, viz., eumenorrheic, oligomenorrheic and amenorrheic. To know the relative frequency (percentage) of different EDs in the study population. To analyze association between eating disorders and PCOS in comparison with normal age-matched controls (non-PCOS women) by eating disorder examination questionnaire (EDE-Q) scores.

It was an institution-based descriptive observational cross-sectional study. After obtaining institutional ethical clearance, consecutive 50 (based on average of previous few years' patient turn up in hospital records) PCOS patients (diagnosed as per Rotterdam criteria, i.e., if at least two of following three criteria are present [10]- (i) oligomenorrhea and/or amenorrhea with chronic lack of ovulation, (ii) clinical and/or biochemical features of hyperandrogenism and (iii) the presence of polycystic ovaries in ultrasonography) between age of 16 and 40 years who attended the outpatient department of department of Obstetrics and Gynecology, Durgapur Steel Plant hospital, Durgapur, West Bengal, between 1st January 2020 and 31st December 2020, and gave explicit consent to participate in the study were included. Patients with other concomitant diagnosed gynecological disorders like malignancy of cervix, ovary, fallopian tube and uterus, uterine or cervical fibroid, endometriosis, adenomyosis and pregnancy were excluded. An equal number of age-matched control women were also included who visited the hospital for other causes. Their demographic variables were taken, past clinical records, menstrual and obstetric history were recorded in a preformed pro forma. Eating disorders were diagnosed using DSM-V [10] criteria. Each participant was administered the EDE-Q, an investigator based interview, that generates two types of scores—global score, which reflects overall severity of ED and subscale scores that reflect the severity of various aspects of the psychopathology of EDs. The subscales are—restraint, eating concern, shape concern and weight concern. EDE-Q global and subscale scores were calculated for each of the participant and compared between PCOS and non-PCOS groups to determine association between EDs and PCOS [2]. All data were collected in a single visit for each participant and entered in MS Excel sheet and analyzed by using SPSS (Version 25). Descriptive statistics has been represented with percentages, and mean with standard deviation. Chi-square test and independent t-test have been employed based on the nature of distribution. P value < 0.05 has been considered statistically significant.

(n = 100) The study included total 100 subjects—consecutive 50 diagnosed PCOS patients and 50 age-matched controls (non-PCOS). PCOS patients were stratified in to four age-groups: 16–25, 26–30, 31–35 and 36–40 years. 22 (44%) patients belonged to age-group 16–25 years, 19 (38%) patients belonged to age-group 26–30 years, and 9 (18%) patients belonged to age-group 31–35 years. No patient was found belonging to age-group 36–40 years. Mean age of PCOS patients is 26.56 years with standard deviation of 4.33 years. An equal number of controls from same age-groups were included (Table 1). Table 1. | Age | Non-PCOS | PCOS | || |---|---|---|---|---| | Count | % | Count | % | | | 16–25 | 22 | 44% | 22 | 44% | | 26–30 | 19 | 38% | 19 | 38% | | 31–35 | 9 | 18% | 9 | 18% | | 36–40 | 0 | 0% | 0 | 0% | | Total | 50 | 100% | 50 | 100% | Height and weight were recorded for each subject and body mass index (BMI) had been calculated and were classified according to the BMI classification for Asian population (Table 2). In the PCOS group-1 (2%) patient was underweight, 22 (44%) patients were overweight, 14 (28%) patients were pre-obese and 13 (26%) patients were obese (obese type 1). None of the PCOS patients were having normal weight. Mean BMI of the patients was 27.58 kg/m2 with standard deviation of 3.32 kg/m2 and range of 17.8–35.8 kg/m2. Table 2. | BMI | Non-PCOS | PCOS | || |---|---|---|---|---| | Count | % | Count | % | | | Underweight (< 18.5) | 1 | 2% | 1 | 2% | | Normal weight (18.5–22.9) | 1 | 2% | 0 | 0% | | Overweight (23–24.9) | 30 | 60% | 22 | 44% | | Pre-obese (25–29.9) | 12 | 24% | 14 | 28% | | Obese type I (30–40) | 6 | 12% | 13 | 26% | | Obese type II (40.1–50) | 0 | 0% | 0 | 0% | | Obese type III (> 50) | 0 | 0% | 0 | 0% | | Total | 50 | 100% | 50 | 100% | *ASIAN criteria of BMI P = 0.291 In the non-PCOS group, 1 (2%) patient was underweight, 1 (2%) patient was having normal weight, 30 (60%) patients were overweight, 12 (24%) patients were pre-obese and 6 (12%) patients were obese (obese type 1). Mean BMI of the control population was 27.03 kg/m2 with standard deviation of 2.62 kg/m2 and range of 18.4–35.3 kg/m2. However, the difference of BMI between the two groups was not statistically significant (P = 0.291 by Chi-square test). All participants, both from PCOS and control group, are residents of urban region as the institution is an industry-based hospital. Forty (80%) patients from the PCOS group are nulliparous, 8 (16%) and 2 (4%) patients are primiparous and multiparous, respectively, whereas 33 (66%) patients from the control group are nulliparous, 11 (22%) and 6 (12%) patients are primiparous and multiparous, respectively (Table 3). Again, this difference in parity between the two sets of population is not statistically significant (P = 0.208 by Chi-square test). Table 3. | Parity | Non-PCOS | PCOS | || |---|---|---|---|---| | Count | % | Count | % | | | Nulliparous | 33 | 66% | 40 | 80% | | Primiparous | 11 | 22% | 8 | 16% | | Multiparous | 6 | 12% | 2 | 4% | | Total | 50 | 100% | 50 | 100% | P = 0.208 In the PCOS group, 11 (22%) patients were suffering from amenorrhea and 37 (74%) patients were suffering from oligomenorrhea. Only 2 (4%) patients were eumenorrheic. In contrast, among the control population, 6 (12%) patients were suffering from amenorrhea, 2 (4%) patients were suffering from oligomenorrhea and 9 (18%) patients were suffering from polymenorrhea. Rest 33 (66%) patients were eumenorrheic (Table 4). Chi-square test showed this difference of menstrual status to be statistically significant (P = 0.0001). Table 4. | Menstrual status | Non-PCOS | PCOS | || |---|---|---|---|---| | Count | % | Count | % | | | Amenorrhea | 6 | 12% | 11 | 22% | | Eumenorrhea | 33 | 66% | 2 | 4% | | Oligomenorrhea | 2 | 4% | 37 | 74% | | Polymenorrhea | 9 | 18% | 0 | 0% | | Total | 50 | 100% | 50 | 100% | P = 0.0001 Finally, as far as ED is concerned, among the PCOS patients—26 (52%) were suffering from binge eating disorder, 7 (14%) were suffering from bulimia nervosa, 1 (2%) was suffering from anorexia nervosa and another 1 (2%) was suffering from restrictive food intake disorder. Rest 15 (30%) PCOS patients did not suffer any ED. However, among the non-PCOS women—4 (8%) were suffering from binge eating disorder, 1 (2%) was suffering from anorexia nervosa and another 1 (2%) was suffering from restrictive food intake disorder. Rest 44 (88%) women did not suffer any ED (Table 5). This difference was found to be statistically significant (P = 0.0003) by Chi-square test. Table 5. | Eating disorder | Non-PCOS | PCOS | || |---|---|---|---|---| | Count | % | Count | % | | | Anorexia nervosa | 1 | 2% | 1 | 2% | | Binge eating disorder | 4 | 8% | 26 | 52% | | Bulimia nervosa | 0 | 0% | 7 | 14% | | No | 44 | 88% | 15 | 30% | | Others (restrictive food intake disorder) | 1 | 2% | 1 | 2% | | Total | 50 | 100% | 50 | 100% | P = 0.0003 EDE-Q global score and subscale scores were calculated among PCOS patients with eating disorder and non-PCOS control women with eating disorder and their means were compared using independent t-test (Table 6). Statistically significant differences between two groups were observed in EDE-Q global score and eating concern, shape concern and weight concern subscale scores, but no significant difference was observed in restraint subscale score. Table 6. | Parameter | Non-PCOS | PCOS | P-value | |||| |---|---|---|---|---|---|---|---| | N | Mean | SD | N | Mean | SD | || | EDE-Q global score | 6 | 0.64 | 0.63 | 35 | 2.29 | 1.22 | 0.0026 | | EDE-Q restraint subscale score | 6 | 0.39 | 0.58 | 35 | 0.78 | 1.09 | 0.4007 | | EDE-Q eating concern subscale score | 6 | 0.71 | 0.76 | 35 | 2.47 | 1.52 | 0.0088 | | EDE-Q shape concern subscale score | 6 | 0.80 | 0.71 | 35 | 2.94 | 1.65 | 0.0036 | | EDE-Q weight concern subscale score | 6 | 0.65 | 0.79 | 35 | 2.78 | 1.74 | 0.0057 |

The study found statistically significant association between PCOS and ED across all domains of ED, viz., global and eating concern, shape concern and weight concern in our patients attending this industry-based specialty hospital setup in eastern India except in restraint domain. This study is in contrast to the findings observed by Pirotta et al. [15] in Australian women in 2019 and Wang et al. [16] in women of the Netherlands through a post hoc cross-sectional analysis in 2021 where they did not find any association between PCOS and ED; However, it is consistent with the findings of meta-analysis by Thannickal et al. [13] in 2020 & review article by Regine et al. [1] in 2020 where they found PCOS is associated with an increased risk of eating disorder. A case–control study by Basar et al. [14] in 2020 and a prospective cohort study conducted at university of California center by Greenwood et al. [4] in 2020 also inferred that PCOS is associated with ED, but in contrast to our study, they found association of PCOS and ED in restraint domain also. Literature suggests insulin resistance and resulting high insulin level in PCOS is followed by intense carbohydrate cravings as a physiological need of the body to raise blood sugar to normal levels. This along with high orexigenic androgen levels and high levels of body dissatisfaction with self-appearance in PCOS (independent of BMI) as observed by Alur Gupta et al. [5], Pesonem et al. [17] and Lee et al. [18] may promote overeating (or sometimes restrictive eating) and development of anxious and depressed mood states which are the key drivers of EDs [6, 10, 19]. Furthermore, EDs like bulimia nervosa itself may create a hormonal environment by altering insulin secretion and insulin resistance which predisposes toward polycystic ovarian changes, as that have been more commonly identified in bulimic women when compared with controls in some studies [6, 13]. There are a very few studies conducted on PCOS and EDs among Indian women and hence there is paucity of conclusive data. This study findings further emphasize that complete treatment of PCOS among our (Indian) patients must necessarily address the psychological correlates associated with this disease, i.e., EDs. Lack of association between PCOS and restraint domain of ED can be explained by high prevalence (1.6%) of binge eating in general population [10]. In terms of frequency, this study found that EDs are significantly more common among PCOS patients—binge eating disorder being the commonest followed by bulimia nervosa, which is consistent with the findings of scoping review by Lalonde-Bester et al. [6] and cohort study by Tay et al. [20]. Now to achieve somewhat conflicting goals of weight loss and psychological well-being for simultaneously addressing PCOS and EDs, taking a more flexible approach to weight management would be optimal in order to prevent accomplishing a “healthy” weight at the cost of psychological well-being. Researches by Isabel Krug et al. showed that such women benefited more undergoing cognitive behavioral therapy (CBT) along with lifestyle changes than lifestyle changes alone [10], whereas Greenwood et al. [2] advocated that the most effective intervention strategy is to first address the ED psychopathology through measures such as CBT before attempting weight loss. So, uniform diet and exercise strategy for all PCOS patients may be counterproductive. We obtained few additional findings from the study. Menstrual abnormality is significantly more common among PCOS patients and majority suffers oligomenorrhea followed by amenorrhea. This finding is consistent with that obtained from Naz et al. [21] and this study revalidates it among our (Indian) study population. BMI is supposed to be an important determinant of PCOS, but this study found no significant difference in BMI among PCOS and general population which is in contrast to that found by Krug et al. [10] and Greenwood et al. [2] where the authors noted that the PCOS group revealed a significantly higher BMI than the control sample. In our study, control population (non-PCOS) has been drawn from industry-based urban population (who visited the hospital for other causes) which might be the reason for this disagreement. Mean age of study population is 26.56 years which is in agreement with the findings observed by Greenwood et al. [2], and it further emphasizes the fact that PCOS is prevalent in young reproductive age-group. Parity was not found to be significantly different in PCOS and general population. This study has certain strengths. All consecutive patients were enrolled that fulfilled the inclusion criteria and consented to participate, thus avoiding sampling bias in the work. Only those patients were enrolled who definitely had PCOS based on the established clinical and biochemical criteria and appropriate age-matched control women were included. Furthermore, interview-based method EDE questionnaire was used for assessing ED, which is a very sensitive and valid tool that reliably characterizes the prevalence of EDs in women with PCOS. However, there are few limitations in this study. The sample size was small and due to the very nature of the setup, only urban patients could be included. Also, women with eating disorders are often very secretive about their eating problems and weight control behavior. Such concealment of information and resulting bias might have affected this study. Hence, larger studies are required on this aspect.

There is a statistically significant association between PCOS and ED across all domains except Restraint domain. Therefore, it is of utmost importance to raise awareness and provide education to women about disordered eating in PCOS so that the beneficial effect of lifestyle interventions on PCOS is not negated. Formalized treatment guidelines need to be formulated for successful management of PCOS and EDs in a holistic manner. A detailed questionnaire for eating disorders in PCOS women is to be developed. Collaborative multidisciplinary effort of various health care professionals including gynecologists, dieticians, mental health professionals, endocrinologists and primary healthcare providers is needed to formulate comprehensive individualized approach for management of PCOS. High degree of clinical suspicion and awareness is required in health professionals for timely diagnosis of both disorders to promote appropriate lifestyle management early on to prevent complications. Also, counseling sessions to be organized for postpubertal adolescent girls so as to prevent the development of a negative self-image and simultaneously knowledge about healthy eating habits imparted. Funding There has been no significant financial support for this work. Declarations Conflict of interest The authors declare that they have no conflict of interest. Ethics Approval Institutional Ethical Clearance was obtained from Durgapur Steel Plant Hospital (established as per NBE guidelines) in 2019. Informed consent Informed consent was obtained from all individual participants included in the study. Footnotes Sulagna Lala, MBBS, DNB, Consultant Gynaecologist & Obstetrician, Senior Resident; Nrityendra Narayan Bhattacharya, MBBS, MS. Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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