Mental illness and sleep disorders among women with gynecological problems

t his retrospective cohort study identifies differences between rates of selected mental illnesses and sleep disorders according to eight gynecological problems. a nalyses utilize medical claims data for adult employees of a large corporation during 2017–2021. Women with a gynecological problem (most notably pain, endometriosis, pelvic inflammation and bleeding) are significantly more likely to experience mental illness. s everal gynecological problems are also significantly associated with sleep disorders. Women with a gynecological problem (vs. none) are 50% more likely to have a mental health problem and 44% more likely to have a sleep disorder after adjusting for age, marital status, dependent children and year. t he largest differences between higher (%) mental illness and sleep disorders appear for hyperplasia (6% vs. 45%), cancer (11% vs. 68%), pelvic inflammation (46% vs. 79%) and pain (79% vs. 43%), respectively. On the other hand, the rate of having one or more gynecological problems ranges from 7.1% for women with no mental illness or sleep disorder to 20.6% for women with schizophrenia. Understanding the association between gynecological problems, mental illness and sleep disorders can help clinicians more effectively identify and treat patients.

Gynecological problems encompass a wide range of conditions, such as vulvodynia, hyperplasia and pelvic inflammation. t hese and other gynecological problems adversely affect women’s psychological health and quality of sleep [ 1,2]. i n turn, mental illness and sleep quality may also adversely affect gynecological prob - lems [ 3,4]. in a recent systematic review of 50 studies and meta-analysis of 31 studies, diagnosis of gynecological problems was associated with a 2- to 3-fold increased odds of having a mental illness [ 5]. s tudies identified in this review and meta-analysis tended to assess the effects of pelvic pain and polycystic ovary syndrome on anxiety, depression and bipolar disorder. s tudies that go beyond those identified in the review involve endome - triosis, uterine bleeding, prolapse and uterine fibroids. a population-based study in s weden found that endometriosis was associated with stress, anxiety, depression and aDhD [ 6]. a study of 96 patients with uterine bleeding and 94 controls found that uterine bleeding was positively associated with anxiety, depression and obsessive-compulsive disorder (OcD) [7]. i n a case-control study involving 75 cases with pel - vic organ prolapse and 65 controls found that cases were five times more likely to have depressive symp - toms [ 8]. i n a study of 313,754 women with uterine fibroids and 627,539 controls, women with uterine fibroids had significantly higher rates of anxiety, depression and self-directed violence, especially among those women who experienced pain symptoms [ 9]. a lthough few studies consider the possible causal direction of mental illness on gynecological problems, a study of 240 case-control pairs of women found that the odds of vulvodynia were four times greater in those with antecedent mood or anxiety compared to women without [ 3]. clinical studies have also shown that women with endometriosis have increased stress, but also that chronic stress can be a cause of endome - triosis [ 4]. © 2024 t he a uthor(s). Published by i nforma uK limited, trading as taylor & f rancis Group CONTACT r ay m. m errill r [email protected] Gerontology Program, brigham young university, 2063 life s cience building, Provo, ut 84604, usa https://doi.org/10.1080/0167482X.2024.2354330 t 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 use, 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 a ccepted m anuscript in a repository by the author(s) or with their consent. ARTICLE HISTORY Received 6 March 2024 Revised 25 a pril 2024 a ccepted 5 May 2024

Medical claims; mental illness; rates; sleep disorder; women 2 R. M. MeRRill aND D. sONG in a study of 838 women aged 31–54  years enrolled in a study of pelvic problems, 33.7% reported poor sleep quality and 46.8% reported short sleep duration [2]. Women with higher pelvic problem scores also were more likely to experience poor sleep. in a case-control study involving 157 women chronic pelvic pain had significantly poorer sleep quality [ 10]. i n a systematic review of 22 papers, insomnia increased 14–60% in ovarian cancer patients [ 11]. i nsomnia was associated with emotional distress, anxiety and depres - sion. i n an age-matched case-control study of 145 women with endometriosis and 145 controls, poor sleep quality was significantly greater in the women with endometriosis (64.8% vs. 15.1%) [ 12]. i n a study of 156 infertile women, endometriosis was associated with lower levels of sleep quality [ 13]. a community-based sample of 579 premenopausal women found that short sleep duration and poor sleep quality were associated with heavier bleeding and menstrual cycle irregularity [ 14]. t he mental illness outcome variables in these stud - ies tend to be anxiety and depression, and the sleep disorder outcome variable tends to be insomnia. Other mental illnesses and sleep disorders may also be of interest. Further, studies have not compared the asso - ciations for a more comprehensive list of gynecological problems, mental illnesses and sleep disorders. Finally, the association between gynecological problems and mental illnesses may change after adjusting for sleep disorders. likewise, the association between gyneco - logical problems and sleep disorders may change after adjusting for mental illnesses. t he purpose of this study was (1) to identify the rate of eight gynecological problems in an adult employee population of women; (2) compare rates of selected mental illnesses and sleep disorders accord - ing to each gynecological problem, adjusting for age, marital status, dependent children and year; and (3) compare rates of having one or more gynecological problems according to each mental illness and sleep disorder.

Study population t he current study involves employees of the church of Jesus christ of latter-day s aints (lDs) receiving health insurance from the Deseret Mutual Benefit administrator (DMBa ). t he DMBa is a subsidiary of the Deseret Management c orporation (s alt lake c ity, Ut ), the global operating company over the church’s for-profit entities. i t has been in operation since 1970 to provide health insurance and retirement income to employees and their families. t he study utilizes electronic claims data for the years 2017–2021. a “claim” is a notification to DMBa requesting a medical benefit payment. We do not include pharmaceutical claims in this paper. Geographic areas represented by enrollees included Utah (74%), idaho (9%), Pacific states (9%) and other a merican states (8%). each year the cohort consisted of approximately 27% employees, 21% spouses, 48% dependent chil - dren and 4% other (e.g. married child, stepchild and disabled dependent). a mong employees, 34% worked in the church education system, seminaries and insti - tutes; 31% as manual laborers; 10% in other compa - nies; 6% were retired; and the remaining 19% worked in other capacities. We do not include retirees in this study. employee retention was about 92% (80% in ages 18–29, 95% in ages 30–64, and 76% in ages 65  years or older) from year to year. t he number of employees insured through DMBa dropped for individ - uals aged 65  years and older as they became eligible for Medicare. Data collection t he study involved the following number of female lDs employees insured through DMBa: 6579 in 2017, 6806 in 2018, 6814 in 2019, 6512 in 2020, and 6652 in 2021. t hese data represent eligibility data linked to automated medical claims records using a common identifying number. Following the linkage of the data and before analysis, the database was de-identified according to health i nsurance Portability and a ccountability a ct (hiP aa ) guidelines. t he authors’ institutional review board approved the study. classification of mental illness, sleep disorders and gynecological problems was based on the international classification of Diseases, tenth Revision, clinical Modification (icD-10- cM) [ 15]. t he Diagnostic and s tatistical Manual of Mental Disorders (DsM) helps psychiatrists, physicians, clinical psychologists and other health professionals diagnose behavioral health issues [ 16]. t he DsM diagnostic crite - ria serve as a guide in determining billing codes according to the icD-10- cM. c odes used to classify mental illnesses are F20–F29 for schizophrenia, delu - sional and other non-mood-psychotic disorders (here - after called schizophrenia); F31 for bipolar disorder; F32–F33 for depression; F40–F41 for anxiety; F42 for OcD; F43 for stress; and F90 for attention deficit hyper - activity disorder ( aDhD). c odes used to classify sleep disorders are G470 (insomnia), G471 (hypersomnia), G473 (sleep apnea), G472 (circadian rhythm sleep JOURNal OF PsychOsOM atic OBstetRics & Gy Nec Ol OGy 3 disorders), G474 (narcolepsy and cataplexy), G475 (parasomnia), G476 (sleep-related movement disor - ders), G478 (other sleep disorders) and G479 (unspeci - fied sleep disorders). c odes used for classifying female gynecological problems include N80 for endometriosis, N81 for prolapse, N85 for endometrial hyperplasia, D25 for leiomyoma of the uterus (fibroids), c51– c58 for cancer, N93 for abnormal uterine and vaginal bleeding, N70–N77 for inflammatory diseases of the female pel - vic organs and N94 for pain and other conditions asso - ciated with the female genital organs and menstrual cycle. Rates consist of the number of enrollees filing one or more claims for each condition divided by the num - ber of enrollees. i f multiple claims are filed by an employee in a year for a specific condition, it is only counted once in the numerator of the rate calculation. however, an individual may contribute to more than one type of mental illness, sleep disorder or gyneco - logical problem each year. t he level of any mental ill - ness in our female employee population is very similar to the prevalence from U.s. National c ross-sectional survey Data. For example, the prevalence of women with a mental illness (icD-10- cM codes F0–F9) in 2017 through 2021 was 21.3%, 22.4%, 24.1%, 25.8% and 26.8%, respectively. t he prevalence identified in U.s. survey data for women in the corresponding years was 22.3%, 22.8%, 24.5%, 25.8% and 27.2, respectively [ 17]. Other variables considered in this study are age, marital status, dependent children status and year. classifications for these variables appear in table 1 . Statistical techniques Numbers, percentages, means, standard deviations and rates described the variables. We assessed whether the levels of mental illness, sleep disorders and gynecolog - ical problems varied across the levels of other vari - ables using the chi-square test. We compared rates using rate ratios, adjusted for age, marital status, dependent children status and year. t he significance of the adjusted rate ratios was determined using the c ochran–Mantel–haenszel test. s tatistical significance was based on two-sided tests and the .05 level. We conducted our statistical analyses using statistical a nalysis s ystem (sas) software, version 9.4 (sas institute inc., c ary, Nc, 2014).

Mental illness affects 24.1%, sleep disorders 9.1% and gynecological problems 8.4% of women. a ges range from 18 to 64 ( M  =  45.9, sD = 12.6). a bout 55.8% of employees are married and 41.3% have dependent children ( table 1 ). Table 1. m ental illness, sleep disorders or female gynecological problems according to selected variables among Dmba employ - ees, 2017–2021. mental illness sleep disorder f emale gynecological problem no. % % p Value % p Value % p Value age 18–49 18,809 56.38 26.04 <.0001 5.33 <.0001 10.17 <.0001 50–64 14,554 43.62 21.57 14.08 6.07 married no 14,754 44.22 26.14 <.0001 8.85 .0983 7.49 <.0001 yes 18,609 55.78 22.46 9.38 9.09 Dependent children no 19,584 58.7 24.24 .4461 9.87 <.0001 8.19 .1290 yes 13,779 41.3 23.88 8.11 8.66 year 2017 6,579 19.72 21.34 <.0001 8.53 .0815 8.22 .2677 2018 6,806 20.40 22.42 8.68 8.54 2019 6,814 20.42 24.13 9.38 8.88 2020 6,512 19.52 25.77 9.46 7.83 2021 6,652 19.94 26.83 9.68 8.42 mental illness no 25,326 75.91 6.53 <.0001 7.28 <.0001 yes 8,037 24.09 17.39 11.86 sleep disorder no 30,312 90.86 21.90 <.0001 8.14 <.0001 yes 3,051 9.14 45.82 10.78 f emale genial problem no 30,566 91.62 23.18 <.0001 8.91 <.0001 yes 2797 8.38 34.07 11.76 t 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– c58, n93, n70–n77 and n94 (female gynecological problems). 4 R. M. MeRRill aND D. sONG Age Mean age is significantly lower for those women with mental illness (45.1 vs. 46.2, p  <  .0001), higher for those women with a sleep disorder (52.8 vs. 45.2, p  <  .0001) and lower for those women with a gynecological prob - lem (43.4 vs. 46.2, p  <  .0001). sleep disorders increase with age. Gynecological problems are greatest in younger aged women. Rates in younger women (ages 18–49 vs. 50–64) are 195.3% ( p  <  .0001) higher for endometriosis, 27.0% ( p  =  .0079) higher for fibroids, 153.6% (p < .0001) higher for bleeding, 54.4% ( p < .0001) higher for pelvic inflammation, and 419.4% ( p  <  .0001) higher for pain. t hey are 66.4% ( p  <  .0001) lower for prolapse and 81.7% ( p  <  .0001) lower for cancer. t here is not a significant difference for hyperplasia. Marital status Marriage is associated with lower rates of mental ill - ness but higher rates of gynecological problems. Rates of gynecological problems in married (vs. single) women are 88.2% ( p  <  .0001) higher for prolapse, 71.2% ( p  <  .0001) higher for hyperplasia, 25.9% (p  =  .0102) higher for fibroids, 40.8% ( p  <  .0001) higher for bleeding, 21.1% ( p < .0001) higher for pelvic inflam - mation, and 22.3% ( p  =  .0037) higher for pain. t hey are 42.5% ( p  =  .0005) lower for cancer. t here is not a significant difference for endometriosis. Dependent children having dependent children is not associated with rates of mental illness or gynecological problems but is associated with lower rates of sleep disorders. t here is no difference in the rates of sleep disorders between women with children and those without children except for sleep apnea (7.36% with no children vs. 5.58% with children, p  <  .0001). Rates of mental illness tend to increase with calendar year. Mental illness and sleep disorders by gynecological problems t he most common types of female gynecological problems are pain, pelvic inflammation and bleeding (table 2 ). Gynecological problems tend to be associ - ated with higher levels of both mental illness and sleep disorders, mental illness only, or sleep disorder only ( Figure 1). c ompared with no gynecological prob - lem, women are 48.2% more likely to have both men - tal and sleep disorders, 41.9% more likely to have mental illness only, and 14.0% more likely to have a sleep disorder only. Pain has the largest association with mental illness and cancer has the largest associa - tion with sleep disorder. Rates of selected types of mental illness and sleep disorders are compared between having (vs. not hav - ing) a gynecological problem, adjusted for age, marital status, dependent children and year ( table 3 ). Women with a gynecological problem are 43.8% more likely to have a mental illness and 50.0% more likely to have a sleep disorder. t he rate of mental illness ranges from 6% higher for women with fibroids to 79% higher for women with pain. similarly, the rate of sleep disorders ranges from 21% higher for women with prolapse to 74% higher for women with pelvic inflammation. stress, anxiety, depression, schizophrenia, insomnia, hypersomnia, sleep apnea and other sleep disorders are significantly greater for women with a gynecologi - cal problem. endometriosis, bleeding, pelvic inflamma - tion and pain are the only gynecological problems Table 2. m ental illness and sleep disorders according to gynecological problems among Dmba employees, 2017–2021. stress a nxiety Depression aDhD bipolar ocD schizophrenia insomnia hypersomnia sleep apnea o ther sleep disorder no. % % % % % % % % % % % % a 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 endometriosis 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 Prolapse 253 0.76 4.35 14.23 11.46 1.58 0.79 0.79 – 3.95 1.98 11.46 1.19 hyperplasia 297 0.89 3.37 14.48 12.12 1.01 0.67 – 0.34 2.02 0.34 12.12 1.68 f ibroids 515 1.54 4.85 14.56 13.40 1.94 – 0.19 0.39 3.50 1.17 8.74 1.94 c ancer 157 0.47 1.91 13.30 12.10 – – – 0.64 2.55 1.27 18.47 0.64 bleeding 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 Pelvic inflammation 728 2.18 6.73 19.37 17.72 2.88 0.55 0.41 0.14 4.26 1.24 9.89 1.65 Pain 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 a ny gynecological problems 2797 8.38 5.97 19.31 17.27 1.97 0.64 0.54 0.25 3.04 1.18 8.40 1.54 aDhD: attention deficit hyperactivity disorder; ocD: obsessive compulsive disorder; (–) no cell counts. o ther sleep disorders refer to circadian rhythms sleep disorders, narcolepsy and cataplexy, parasomnia, sleep related movement disorders, other sleep disorders and unspecified sleep disorders. JOURNal OF PsychOsOM atic OBstetRics & Gy Nec Ol OGy 5 linked to mental illnesses. t he rate ratios for schizo - phrenia are the largest, but because of small numbers tend to not be statistically significant. Rates of mental illness and sleep disorders accord - ing to whether the selected gynecological problems exist appear in Figure 2 . Women with hyperplasia, Figure 1. r ate of mental illness and/or sleep disorder according to status of gynecological problem. Table 3. r ates of mental and sleep disorders according to gynecological problems among Dmba employees, 2017–2021. stress a nxiety Depression aDhD bipolar ocD schizophrenia a ny mental illness insomnia hypersomnia sleep apnea o ther sleep disorderb a ny sleep disorder r ate ratio a endometriosis 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 Prolapse 1.43 1.23 1.00 1.10 1.27 3.73 – 1.13 1.17 2.14 1.27 1.14 1.21 hyperplasia 0.92 1.10 1.01 0.69 0.96 – 4.59 1.06 0.72 0.39 1.74 1.85 1.45 f 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 c ancer 0.56 1.22 0.98 – – – 4.46 1.11 0.70 1.30 1.85 0.76 1.68 bleeding 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 Pelvic inflammation 1.89 1.44 1.47 1.79 0.80 1.12 1.65 1.46 1.83 1.67 1.74 2.18 1.74 Pain 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 a ny gynecological problems 1.72 1.46 1.46 1.19 0.90 1.45 3.62 1.44 1.29 1.67 1.51 2.18 1.50 aDhD: attention deficit hyperactivity disorder; ocD: obsessive compulsive disorder; (–) no cell counts. shaded cells are statistically significant at the .05 level. aa djusted for age, marital status, dependent children and year. bo ther sleep disorders refer to circadian rhythms sleep disorders, narcolepsy and cataplexy, parasomnia, sleep related movement disorders, other sleep disorders and unspecified sleep disorders. 6 R. M. MeRRill aND D. sONG Figure 2. r ates of mental and sleep disorders according to female gynecological problems. r ate ratios adjusted for age, marital status, dependent children and year. Figure 3. r ate of having a gynecological problem according to types of mental illnesses and sleep disorders. JOURNal OF PsychOsOM atic OBstetRics & Gy Nec Ol OGy 7 cancer, bleeding and pelvic inflammation have higher rates of sleep disorders than mental illness. For exam - ple, women experiencing bleeding are 27.7% more likely to have mental illness and 60.0% more likely to have sleep disorders. On the other hand, women expe - riencing pain associated with female genital organs and menstrual cycle have higher rates of mental illness than sleep disorders. For example, women experienc - ing pain are 78.7% more likely to have mental illness and 43.1% more likely to have sleep disorders. We now consider the rate of one or more gyneco - logical problems in women with a mental illness or sleep disorder ( Figure 3 ). t he rate of gynecological problems is greater for each of the mental illnesses and sleep disorders compared with no mental illness or sleep disorder. Women with schizophrenia have the highest rate of gynecological problems.

t his study identified the rate of eight gynecological problems in an adult employee population. i t compared rates of selected mental illnesses and sleep disorders according to each gynecological problem, adjusting for age, marital status, dependent children and year. Rates of having one or more gynecological problems accord - ing to each mental illness and sleep disorder were also presented. an important strength of this study is its size and that several gynecological problems are evaluated simulations, according to their relationship with mental illness only, sleep disorders only, and a combination of both mental illness and sleep disorders. a ge, marital status and dependent children show important relationships with mental health, sleep and gynecological conditions. t he rate of mental illness is greatest in the ages 30–49. t his is consistent with mental health services received in the past year among U.s. adults with any mental illness [ 18]. t he rate of sleep disorders increases with age, as consis - tent with other research [ 19]. t his increase with age may be because older age is positively associated with factors that negatively affect sleep. Rates of gynecological problems are greatest in the ages 30–49  years and lowest in the ages 50–64  years. a lthough this result is for all gynecological problems combined, a separate analysis showed that the age pattern is unique to the given gynecological problems (data not shown). For example, prolapse and cancer increase with age, and bleeding and inflammation decrease with age. Marriage is associated with a lower rate of mental illness, as found in other studies [ 20–22]. i n contrast, marriage is associated with higher rates of gynecological problems like prolapse, hyperplasia, fibroids, bleeding, pelvic inflammation and pain. h igher rates in married women continue after adjusting for age, dependent children and year (data not shown). t his result may be because married women are more likely to seek medical care for their gynecological problems. Research has shown that marriage can encourage health-promoting behaviors such as health - care utilization [ 23]. a lthough having dependent children is not associ - ated with rates of mental illness or gynecological problems, it is associated with lower rates of sleep dis - orders. t his may be because women who have chil - dren are healthier in general and better health is associated with lower rates of sleep disorders. For example, women with obesity, type 2 diabetes, hyper - tension or cardiovascular disease have a higher risk of sleep disorders [ 24]. t he most common gynecological problems involve bleeding, pelvic inflammation and pain. For these gynecological problems, as well as endometriosis and fibroids, rates are higher prior to menarche. Menstrual disorders include abnormal uterine bleeding, fibroids, and severe physical and emotional discomfort (pain and cramping) prior to menstruation. Pelvic inflamma - tion usually occurs from sexually transmitted bacteria of one or more of the upper reproductive organs (uterus, fallopian tubes and ovaries), which may develop into chronic pelvic pain. c onsistent with our results, pelvic organ prolapse is more common in older women [ 25]. Rates of mental illness compared with rates of sleep disorders according to the status of the gynecological problems are significantly different for a few of the gynecological conditions. h yperplasia, cancer, bleeding and pelvic inflammation are more strongly associated with sleep disorders (with sleep apnea significant for each condition), and pain is more strongly associated with mental illness (primarily stress, anxiety and depres - sion). t he strong association between pelvic inflamma - tion and sleep disorders is consistent with previous research [2,10]. c ancer has the second strongest associa- tion with sleep disorders, primarily involving sleep apnea. t his result is consistent with a systematic review and meta-analysis [26]. t his may be due to both having com - mon risk factors such as cigarette smoking and excessive weight, but also because a greater risk of cancer is linked to oxygen deprivation and serious blood clots in the veins caused by sleep apnea [ 27]. t he prevalence of anxiety, depression and substance use disorders is com - mon in people with chronic pain, and anxiety and depression can lead to behaviors (e.g. cigarette smoking and substance abuse) that contribute to pain [ 28]. 8 R. M. MeRRill aND D. sONG endometriosis, bleeding, pelvic inflammation and pain are the only gynecological problems significantly associated with mental illnesses. Other studies have also found these associations [ 5–7]. For example, in a cross-sectional study of 212 women with chronic pel - vic pain, higher pain severity was associated with greater stress and anxiety [ 29]. i n a cross-sectional study of 100 women with chronic pelvic pain and 100 women without chronic pelvic pain, the prevalence of anxiety was 66% in the control group and 49% in the controls ( p  =  002) [ 30]. t he prevalence of depression was 63% in the chronic pain group and 38% in con - trols ( p  <  .01). however, other studies also found sig - nificant associations between prolapse, uterine fibroids and mental illness. a lthough we found that those with prolapse were 12.8% more likely to experience any mental illness and those with fibroids were 14.0% more likely to experience mental illness, the insignifi - cant results may be due to small numbers. stress, anxiety and depression are most consistently associated with gynecological problems. aDhD is not significantly associated with gynecological problems overall but is significantly associated with pelvic inflammation. Research has shown that inflammation can negatively affect brain structure, resulting in neu - rodevelopmental disorders like aDhD [ 31]. a lthough a population-based study in sweden found that endo - metriosis was associated with aDhD [ 6], we did not find this result. t he large sample size in that study may explain their significant findings. t he association between gynecological problems and schizophrenia is significant. Women with schizo - phrenia are most likely to have a gynecological prob - lem (see Figure 3 ). s tress and major dramatic life changes can trigger schizophrenia. i t is possible that schizophrenia may be precipitated by female gyneco - logical problems and associated stress and anxiety. a ssociations for the individual gynecological sites and schizophrenia are larger than for the other mental ill - nesses, but small numbers limit finding statistical sig - nificance, except for bleeding (see table 3). t he positive association between gynecological problems and schizophrenia is consistent with previous research [ 32]. t he association between abnormal uterine bleeding and schizophrenia may be partly explained by sex-hormonal imbalance in schizophrenia patients, which is sometimes attributed to a hyperprolactinemia effect of antipsychotics [ 33]. t he current study has certain limitations. Rates were based on employees who filed healthcare claims. some less serious cases of mental illness and sleep disorders may not have sought medical attention. c onsequently, they would not be represented in the prevalence esti - mates. however, our overall estimated level of mental illness based on medical claims is almost the same as national estimates from cross-sectional surveys (see the “Data collection” section). large ranges reported in the literature on sleep disorders among adult women make it difficult to determine whether the current

are noticeably underestimating the prevalence of sleep disorders for less serious cases. Nevertheless, we do believe that the current study accurately reflects the prevalence of mental illness and sleep disorders in chronic cases. i n addition, combinations of types of gynecological problems and mental illness or sleep disorders sometimes involved small numbers, which limited determination of statistical significance, espe - cially for schizophrenia. Further, the current study focused on an employee population aged 18–64  years, primarily from the Western United s tates. employees and younger people tend to be healthier than the general population, so generalization of the results should be done with caution. Finally, the current study is limited to identifying statistical associations and not causal relationships.

Gynecological problems cover a range of conditions that can significantly impact women’s mental and physical health. Gynecological problems are associated with higher rates of stress, anxiety, depression, schizo - phrenia, insomnia, hypersomnia, sleep apnea and other sleep disorders. Women with a gynecological problem (vs. none) are 50% more likely to have a men - tal health problem and 44% more likely to have a sleep disorder, after adjusting for age, marital status, dependent children and year. On the other hand, the rate of mental illness or sleep disorders has higher rates of gynecological problems, especially in women with schizophrenia (20.6%). Understanding the associ - ation between gynecological problems, mental illness and sleep disorders can help clinicians more effectively identify and treat patients.

t he authors wish to thank Glenn Barrett for preparing the data files used in the current study. Ethical approval t his study was performed in line with the principles of the Declaration of helsinki. t he authors’ institutional review board approved the study (iRB2021-157). JOURNal OF PsychOsOM atic OBstetRics & Gy Nec Ol OGy 9 Consent form Not applicable. Disclosure statement No potential conflict of interest was reported by the author(s). Funding No funding was received for this article. Data availability statement t he datasets generated and/or analyzed in this study are available from the corresponding author upon reasonable request.

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