==== Front Int J Womens HealthInt J Womens HealthInternational Journal of Women's HealthInternational Journal of Women's Health1179-1411Dove Medical Press 10.2147/IJWH.S165794ijwh-10-397ReviewMeasures of health-related quality of life in PCOS women: a systematic review Behboodi Moghadam Zahra 1Fereidooni Bita 2Saffari Mohsen 3Montazeri Ali 4 1 Department of Reproductive Health, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran 2 Department of Reproductive Health, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran, barshimah@yahoo.com 3 Health Research Center, Life Style Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran 4 Population Health Research Group, Health Metrics Research Center, Iranian Institute for Health Sciences Research, ACECR, Tehran, Iran, montazeri@acecr.ac.irCorrespondence: Bita Fereidooni, Department of Reproductive Health, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tohid Square, East Nosrat St, Tehran, Iran, Email barshimah@yahoo.comAli Montazeri, Population Health Research Group, Health Metrics Research Center, Iranian Institute for Health Sciences Research, Academic Center for Education, Culture and Research, Tehran, Iran, Email montazeri@acecr.ac.ir2018 01 8 2018 10 397 408 © 2018 Behboodi Moghadam et al. This work is published and licensed by Dove Medical Press Limited2018The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.Introduction Polycystic ovary syndrome (PCOS) is associated with biochemical and hormonal disturbance and adverse cosmetic, reproductive, metabolic, and psychological consequences, resulting in reduced health-related quality of life (HRQoL). Various generic and specific questionnaires have been used for assessing different dimensions of HRQoL in PCOS women. The purpose of this systematic review was to identify those general and specific instruments and to determine the factors that affect HRQoL in PCOS women. Materials and methods The research strategy involved general and specific terms in relation to PCOS women and their QoL. A review was performed on studies that were published between 1945 to 2017 and that were indexed in MEDLINE, ISI Web of Science, and Scopus. A narrative synthesis of the data was provided. Results In total, 52 studies (9 qualitative and 43 quantitative) were included in the review. The analysis indicated that 3 specific and 5 general instruments were used to measure the QoL in PCOS women. Of these, the 36-Item Short Form Health Survey (SF-36) and the Polycystic Ovary Syndrome Health-Related Quality of Life Questionnaire (PCOSQ) were used most frequently. All studies assessed different aspects of QoL in PCOS women and found that PCOS had negative effects on QoL in this population. Conclusion The PCOSQ and the SF-36 were used most frequently for the assessment of QoL in PCOS women. Perhaps using either a specific questionnaire solely or a specific questionnaire in conjunction with a generic measure would be more appropriate when measuring QoL in PCOS women. However, both questionnaires showed that they are able to capture different aspects of QoL in PCOS women and to identify areas that can help to improve QoL in these women. Keywords polycystic ovary syndromehealth-related quality of lifequestionnairessystematic review ==== Body Introduction Polycystic ovary syndrome (PCOS) is the most common hormonal disturbance that, depending on the population studied and diagnostic criteria, affects up to 15%–20% of women at reproductive age.1,2 The pathophysiology of this heterogeneous disease has not been clearly determined, but it is believed that it results from complex interactions between genetic, metabolic, and environmental factors.3 It is characterized by hyperandrogenism, ovulatory dysfunction, and polycystic ovarian morphology.4 PCOS is associated with adverse clinical complications including reproductive (menstrual irregularity and infertility),2,3 metabolic (insulin resistance, diabetes, and cardiovascular risk),5 and psychological disabilities (anxiety and depression).6 All have been mentioned as factors responsible for the reduction of life quality.7 Health-related quality of life (HRQoL) is a multidimensional concept used to describe physical, emotional, and social aspects of particular diseases or their treatment.8 Chronic disorders such as PCOS may have major effects on the QoL that need to be precisely assessed.9 HRQoL can be assessed using both general and specific tools. General tools have generally no questions for specific conditions and diseases.10 Therefore, specific tools are generally preferable for each condition assessed, and PCOS is no exception. However, both tool types have been used for measuring QoL in the literature. The aims of this study were to identify 1) studies that have used standard instruments to measure HRQoL in women with PCOS; 2) general and specific instruments that have been used for assessing HRQoL in PCOS women; and 3) the effects of PCOS on different aspects of women’s QoL. Methods Search engines The electronic databases searched included MEDLINE (January 1950–March 2017), ISI Web of Knowledge (January 1945–26 July 2017), Scopus (May 2000–January 2017), and Google Scholar (March 1996–January 2017). More data were collected from the reference lists and databases related to scientific conference, and we contacted the authors of the publications to know they had any other studies which had remained unpublished. Search strategy In the current systematic review article, we managed to find general and specific instruments that assessed QoL, and we further delineated the factors relevant to QoL in women suffering from PCOS using key words: (questionnaire OR scale OR inventory) AND (“Quality of life” OR “Health-related quality of life” OR “Patient-Reported Outcome”) AND (“Polycystic ovary syndrome” OR “PCOS”). Inclusion criteria The following criteria were used to decide which relevant resources to be included: Document type: article; Article type: original, review, and theoretical; Language: English; Study design: qualitative, quantitative, and mixed methods; Species: humans; Subject: health and medicine; Documents’ subjects: QoL and its related factors in PCOS women; and Questionnaire used for HRQoL: measured more than one dimension. Data synthesis Two authors were asked to go through the title and abstract of the studies obtained and to read the full texts finally to decide which studies had met the criteria to be included in the current systematic review. The variables of interest were the first author’s name, year, country, study design, and study results. The two authors negotiated any disagreements to reach consensus. In order to assess HRQoL measures, the Consensus-based Standards for the Selection of Health Status Measurement Instruments checklist was employed. Specifically, we assessed measures for the following criteria: internal consistency, reliability, content validity, construct validity, and factor analysis.11 Results Statistics In all, 4,269 citations were identified. After removing duplicates (n=486), the remaining 3,783 citations were assessed, and an additional 3,161 irrelevant records were excluded. Of the remaining 622 papers, 570 articles were also removed because they were not eligible, and finally 52 full-text articles were included in the analysis (Figure 1). Of these, 9 studies were qualitative and had focused upon the impact of PCOS on patients’ HRQoL.12–20 The remaining 43 studies were quantitative which are summarized in Table 1. The frequency of studies on QoL in PCOS women from various countries (n=52) was as follows: USA (n=13), UK (n=9), Iran (n=7), Australia (n=3), Germany (n=5), Sweden (n=2), Italy (n=2), Canada (n=2), the Netherlands (n=2), and Brazil (n=2). In addition, there was one article from each of the following countries: Belgium, Turkey, Austria, Taiwan, and Greece. Table 2 displays and summarizes different components of QoL in PCOS women. Instruments used Various general and specific questionnaires were used to assess QoL in PCOS women. Overall, three specific and 5 general measures were used to assess the QoL in PCOS women. Of these, one general instrument (36-Item Short Form Health Survey [SF-36]) and one specific instrument (Polycystic Ovary Syndrome Health-Related Quality of Life Questionnaire [PCOSQ]) were used most frequently (Table 3). The generic questionnaires were the following: the SF-36 (n=17), Symptom Checklist-90-Revised (SCL-90-R; n=5), World Health Organization Quality-of-Life-BREF (WHOQOL-BREF; n=4), Child Health Questionnaire-Child Form (CHQ-CF87; n=3), and General Health Questionnaire-28 (n=1). The PCOS disease-specific instruments were the PCOSQ (n=20), the Modified PCOSQ (MPCOSQ; n=3), and the Polycystic Ovary Syndrome Questionnaire (PCOSQ-50; n=1). In the following sections, a short description for each of these is presented. PCOSQ/MPCOSQ The PCOSQ is an instrument that was specifically designed and validated to evaluate HRQoL in PCOS.21–23 In the first stage of the instrument development, 182 items were incorporated which belonged to 8 areas chosen as a result of running semi-structured interviews with 10 patients suffering from PCOS and an extensive literature review.21 In item reduction phase, 100 women with PCOS completed the instrument, and they identified the items of highest impact on their daily lives. By considering the factors influencing women and identifying the items that clinicians take as important, a factor analysis was performed, and the final questionnaire containing 26 items was provided. The PCOSQ contains the following domains: emotions (8 items), hirsutism (5 items), weight (5 items), infertility (4 items), and menstrual disorders (4 items). Each item can be answered by choosing from a Likert scale with 7 options from 1 (always) to 7 (never). Higher scores are indicative of better function. Studies that incorporated the PCOSQ revealed that women with PCOS had functioning impairments pertinent to some measured domains.24–29 However, the relative degree of impairment caused by each domain varied in societies depending on the religious, racial, cultural, and social factors.24 Excess body weight has been widely reported as an important concern to women with PCOS, especially in adolescents.27,30–32 In two more studies that were carried out in Australia and Germany, body weight domain was found to have the strongest association with lower QoL.33,34 The psychometric properties of PCOSQ are well documented in several studies indicating that it is a reliable and valid measure for assessing QoL in PCOS women.22,23,25,35 However, the PCOSQ was modified by Barnard et al, and 4 questions were added to it in order to evaluate issues associated with acne.33 Thus, the MPCOSQ includes 30 questions from 6 HRQoL domains: emotional disturbance (8 items), weight concerns (5 items), infertility (4 items), acne (4 items), menstrual symptoms and predictability (4 items), and hirsutism (5 items). Each item was rated on a 7-point Likert scale where higher scores represent better function. The psychometric properties of the MPCOSQ were promising.33 Using this instrument, Bazarganipour et al in a cross-sectional study of 300 women with PCOS found that infertility and menstrual domains were the most affected areas of HRQoL.36 PCOSQ-50 The PCOSQ-50 was specifically developed by Nasiri-Amiri et al for measuring QoL in PCOS women.37 They used a mixed-method, sequential, exploratory design to define the components of health-related QoL questionnaire and assessed the psychometric properties of instrument. A rudimentary questionnaire composed of 147 items was designed drawing on the findings of a qualitative study that was carried out with 23 Iranian women who suffered from PCOS. Exploratory factor analysis helped to reduce the number of items from 147 to 50. The ultimate draft of the questionnaire incorporated 50 items representing 6 areas, namely emotion, obesity and menstrual disorders, fertility, sexual function, hirsutism, and coping. Each item could be answered by selecting from options on a 5-point Likert scale with higher scores meaning better condition. The analysis of the psychometric properties of the questionnaire revealed promising results. SF-36 The SF-36 is one of the most acknowledged and most frequently used instruments to measure QoL. The SF-36 is used in all types of patients and has been validated in many countries. This instrument has been proved to be reliable and widely validated and has been employed in the assessment of HRQoL in various medical conditions. It consists of 36 items tapping into 8 subscales, namely physical functioning, role physical, bodily pain, general health, vitality, social functioning, role emotional, and mental health.38 The scores on each domain range from 0 to 100 where the higher scores indicate better conditions. Several studies used the SF-36 in order to assess HRQoL in PCOS patients.30,39–42 Findings have been rather consistent in revealing lower HRQoL in women suffering from PCOS. However, evidence suggests that poor QoL in these women might be due to obesity. In some studies, it has been shown that body mass index (BMI) was a predictor of physical functioning as measured by the SF-36.43,44 Furthermore, by using a multivariable regression model, Panico et al in a recent study indicated that BMI is a predictor of physical functioning score.44 Jones et al found that the role 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.23 In a study by Coffey et al, the psychological dimension was more affected than the physical dimension as measured by the SF-36.25 Bazarganipour et al found that PCOS affected all domains in the SF-36, and psychological domains were most affected by PCOS.45 SCL-90-R The SCL-90 has also been widely used and extensively validated. It includes 90 items grouped into 10 main domains, namely somatization, obsessive–compulsive, interpersonal sensitivity, depression, anxiety, aggression, phobia, paranoid ideation, psychoticism, and sleep disorders.46 Three global areas are measured, including the Global Severity Index, Positive Symptom Distress Index, and Positive Symptom Total. For each item related to a single domain, a score ranging from 0 (not at all) to 4 (very much) can be selected. Higher scores represent less favorable conditions.44 Some studies targeting adult women suffering from PCOS have employed the SCL-90 to measure life quality.30,40,44,47,48 By using this tool, Elsenbruch et al showed that emotional distress and obesity in PCOS women are associated with significant decrease in HRQoL.40 WHOQOL-BREF WHOQOL-BREF instrument is comprised of 26 items, which measure broad domains consisting of physical health, psychological health, social relationships, and environment. The WHOQOL-BREF is a shorter version of the original instrument and can be used for assessing the QoL in different cultures and populations. In a study on 146 women having PCOS and 170 controls who were assessed by the WHOQOL-BREF questionnaire, it was discovered that the hirsutism scores were a major predictor of psychological distress and showed correlation with the emotion domain.49 In Benetti-Pinto et al’s study, the BMI was inversely correlated to the QoL in women suffering from PCOS, mainly with the physical, psychological, and environmental aspects of QoL.50 CHQ-CF87 The CHQ-CF87 is a self-report questionnaire that was developed and validated at the Health Institute of the New England Medical Center in Boston.51 It has been used to measure HRQoL in general populations of youth. It consists of 12 summated scales and is designed to measure both the physical and psychosocial HRQoL of adolescents. The items on the CHQ-CF87 are scored from 0 to 100 except for the change in health in the last year, and the items on family cohesion subscales are scored from 1 to 5 as single-item measures. A higher score on each subscale indicates better QoL in a specific area or health improvement in the last year. Trent et al in their study used the CHQ-CF87 and revealed that HRQoL scores of adolescents suffering from PCOS were significantly lower in 4 areas of physical functioning, general health perceptions, behavior, and family activities as measured by the questionnaire.52 These authors also carried out another study in this area and evaluated the influence of BMI on QoL disturbances in adolescent patients. PCOS adolescents had higher BMI than those of the controls and a significantly lower HRQoL. Similarly, PCOS girls scored lower on the general health perceptions, physical functioning, family activities, and the general behavior subscales of CHQ-CF87.53 Discussion The studies identified in this review have shown that PCOS is a major cause of psychological morbidity and has a negative impact on women’s HRQoL. This feature has also been demonstrated in some qualitative studies.13,14,16,19 In all the studies reviewed, different aspects of the QoL in PCOS women were evaluated including physical, psychological, social, sexual as well as medical ones. The impact of PCOS on the HRQoL may be more specifically seen in the perception of values and culture;24 therefore, the major contributing factors of reductions of life quality in PCOS were discovered to be different in a variety of population. However, physical aspects of QoL may be best predicted by obesity and hirsutism.29,49 Excess body weight has been widely reported as an important concern to women with PCOS, especially in adolescents.27,30–32 Obesity is believed to be a primary source for poor HRQoL and contributes substantially to negative psychological symptoms in women with PCOS.54 The findings of an Italian study that was recently performed yielded a significant aggravation of HRQoL in PCOS patients with obesity compared with controls.44 Hirsutism can be found in nearly 70% of women suffering from PCOS,2 and patients take it as one of the most annoying aspects of PCOS.29,55 Women suffering from PCOS who experience hirsutism have often complained that they feel “unfeminine.”12,30,56,57 The comparison of psychological well-beings between women suffering from PCOS and control groups showed an increased risk for emotional distress in those with PCOS.6 Recent meta-analysis in PCOS women has yielded a raise in the prevalence of both depressive and anxiety symptoms in women suffering from PCOS in comparison with controls.58 Loss of femininity, body image concerns, and coping with these conditions may all contribute to poorer mental health outcomes.59 Moreover, changes in body dimensions and physical beauty as well as imbalance of sexual hormones could lead to reduction in QoL and sexual performance. Psychological distress from long-term health risks, infertility, and changes in appearance (obesity, acne, and hirsutism) can influence sexual function among PCOS women.50,60 These women often complain that they feel less attractive and being less sexually satisfied in comparison with non-PCOS women.30 PCOS can also affect patients’ QoL socially. Based on the results of qualitative studies, other factors that affected QoL were the reduction of interpersonal and social relationships.61,62 Accordingly, Ekbäck et al in their qualitative study showed that hirsutism causes severe psychological burden and negatively affected patients’ HRQoL and social interactions.14 A few studies explored the impact of treatment on HRQoL. In 2009, Rofey et al showed that an enhanced cognitive behavioral therapy was practical and encouraging for adolescents suffering from PCOS.41 One of the major findings of the current research was the high frequency of application of specific and general instruments such as PCOSQ and SF-36. In our review, 24 studies had used specific tools for this purpose, and general questionnaires had been applied in other studies. PCOS affects women both psychologically and physically according to the SF-36. A recent meta-analysis showed that women with PCOS score lower in each dimension of the SF-36, mostly in the “Role Emotional” subscale.7 General tools are designed to measure HRQoL in a wide range of diseases and therefore may not be sensitive enough to be used in specific conditions.63 However, specific tools such as PCOSQ include some certain questions for these conditions. Obesity, hirsutism, irregular menses, and infertility are different aspects of PCOS exerting negative impacts on HRQoL that would not easily be detected by employing only a generic questionnaire. By using PCOSQ, it was demonstrated that clinical symptoms of PCOS, especially excess body weight22,23,25–27 and hirsutism,29 could compromise women’s QoL. Ideally, employing both general and specific disease instruments in measuring HRQoL is recommended in order to make comparisons possible at a generic level and especially in the case of the disease under focus.64 Conclusion PCOS symptoms can result in remarkable worsening of life quality and may be highly stressful, adversely affecting psychological, social well-being and sexuality. This study revealed that the specific questionnaire PCOSQ and the SF-36 were mainly used for measuring life quality in women having PCOS. Perhaps using either a specific questionnaire solely or a specific questionnaire in conjunction with a generic measure would be more appropriate when measuring QoL in PCOS women. However, both questionnaires showed that they are able to capture different aspects of QoL in PCOS women and to identify areas that can help to improve QoL in these women. Acknowledgments We would like to thank the Tehran University’s vice-chancellor of education and vice-chancellor of research and technology for their financial support to carry out the study. This article is a part of the PhD thesis of Bita Feridoni supported by Tehran University of Medical Sciences (the ethics code: IR.TUMS.FNM.REC.1395.781). Disclosure The authors report no conflicts of interest in this work. Figure 1 The flow diagram of the review. Table 1 Quantitative studies that measured HRQoL of women with PCOS (n=43) Study; country Design Objective Diagnosis criteria Age (years, mean ± SD) HRQoL instruments used Sample size Main outcomes Cronin et al;21 USA Cross-sectional Designing tools for measuring the QoL in women with PCOS NIH 18–45 PCOSQ 100 PCOS; 12 interviews Developing PCOSQ, which includes 26 items Wong et al;65 Canada Cross-sectional Examining the relative impact of the number and severity of patient problems on HRQoL Not stated 30.5±6.7 PCOSQ 100 Including all potential items in calculating a domain score provided a more accurate portrait of HRQoL Trent et al;52 USA Cross-sectional Evaluating the HRQoL in adolescents with PCOS and its correlation with patients’ perception NIH 13–22 CHQ-CF87 146 control, 97 PCOS Patients had worsened QoL. Patients with higher self-perceived severity scored were lower on the general health perception Trent et al;66 USA Cross-sectional Evaluating the fertility concerns and sexual behavior in young PCOS women compared with healthy women NIH 13–22 CHQ-CF87 146 control, 97 PCOS PCOS women were 3.4 times more likely to be worried about fertility issues Elsenbruch et al;30 Germany Case–control Evaluating the quality of life, mental status, and sexual satisfaction in PCOS women NIH Controls: 29.9±5.7; PCOS: 28.4±5.0 SF-36, SCL-90-R 50 control, 50 PCOS PCOS caused a major reduction in the QoL and severely limits sexual satisfaction Hashimoto et al;67 Brazil Case–control Evaluating the impact of weight status on symptom perception and QoL in PCOS women with different background NIH Brazilian: 25.5±3.9; Austrian: 23.8±4.7 PCOSQ 50 control, 50 PCOS In Brazilian women, hirsutism and in Austria obesity had the greatest impact on QoL Guyatt et al;22 Canada Cross-sectional Measuring the psychometric properties of the PCOSQ NIH 29.4±5.7 PCOSQ 393 Factor analysis provided moderate to strong support for the 5-domain structure of the PCOSQ Schmid et al;24 Austria Cross-sectional Study of infertile PCOS patients QoL with different ethnic and cultural backgrounds Not stated 18–39 PCOSQ 14 Muslim, 35 Austrian PCOS HRQoL of women with an Islamic background was affected to a greater degree than that of Austrian women Jones et al;23 UK Cross-sectional Measuring the psychometric properties of the PCOSQ NIH – PCOSQ, SF-36 92 The PCOSQ is a reliable instrument for measuring the HRQoL Van Wely et al;68 the Netherlands Interventional Evaluating the impact of laparoscopic electrocautery of the ovaries versus recombinant FSH on the PCOS patients’ HRQoL Rotterdam Electrocautery: 28.5±3.7; FSH: 28.7±4.1 SF-36 Electrocautery: 83, FSH: 85 HRQoL was not affected in both groups. FSH treatment was slightly more burdensome for women’s HRQoL than electrocautery Clayton et al;69 UK Interventional Evaluation the effect of laser on the severity of facial hirsutism and on psychological complications in PCOS women Not stated PCOS: 33.0±8.0; control: 32±6.5 WHOQOL-BREF 37 control, 51 intervention Laser treatment reduced the severity of facial hair as well as alleviating depression and anxiety in patients McCook et al;27 USA Cross-sectional Evaluating the influence of the major clinical features of PCOS on patients’ QoL Not stated 20–41 PCOSQ 128 The most common HRQoL concern reported by women with PCOS was weight. BMI and fertility loss had the greater impact on QoL Trent et al;53 USA Cross-sectional Assessing the BMI impact on the QoL of adolescents with PCOS NIH 13–22 CHQ-CF87 146 control, 97 PCOS BMI is a primary mediator in the relationship between PCOS and HRQoL reductions Hahn et al;47 Germany Case–control Examining the extent of different PCOS manifestations on QoL, psychosocial well- being, and sexual satisfaction NIH PCOS: 29.0±5.4; control: 30.0±5.7 SF-36, SCL-90-R 120 control, 50 PCOS PCOS patients showed significant reductions in QoL, psychosocial well-being, and sexual satisfaction Elsenbruch et al;40 Germany Cross-sectional Evaluation of psychological stress in untreated PCOS patients and to assess the impact of emotional distress on QoL NIH 31.3±1.3 SF-36, SCL-90-R 143 Majority of patients exhibited psychological disturbances. Emotional distress together with obesity leads to large decrements in QoL Lipton et al;70 UK Cross-sectional Assessing the behavioral and psychological burden of facial hair in PCOS women Not stated 33.0±7.4 WHOQOL-BREF 88 Facial hair carries a high psychological burden for women. 29% of patients reported depression and anxiety Coffey et al;25 UK Case–control Comparing the QoL in women with PCOS with the general population and patients with other medical conditions AES PCOS: 27.5; control: 28.8 SF-36, PCOSQ 22 control, 96 PCOS PCOS had a negative impact on HRQoL even when compared with other medical conditions (asthma, epilepsy, diabetes, arthritis, and coronary heart disease) Hahn et al;39 Germany Interventional Evaluation the effects of metformin treatment on HRQoL, emotional well-being, and sexuality in PCOS women NIH Rotterdam 29.3±6.3 SF-36, SCL-90-R 327 Treatment improved the psychosocial, emotional, and psychosexual situation of PCOS patients Barnard et al;33 UK Cross-sectional Assessing the quality of life of women with PCOS, studying the factor analysis and adding acne factor Rotterdam 31.0±6.5 MPCOSQ 935 control, 424 PCOS The PCOSQ was modified to include acne. The PCOS groups had significantly worse QoL than controls Drosdzol et al;60 the Netherlands Case–control To evaluate the effect of PCOS on QoL and marital sexual satisfaction Rotterdam 19–40 SF-36 40 control, 50 PCOS PCOS decreased QoL and sexual functioning among women. A negative effect of hirsutism severity on general well- being and sexual life was also observed Ching et al;26 Australia Case–control Evaluation of QoL and psychological complications in PCOS women, compared the findings with general norms NIH PCOS: 15–65; control 18–44 SF-36, PCOSQ, GHQ-28 173 control, 203 PCOS Impaired QoL and increased prevalence of psychological morbidity in PCOS compared with population norms were obtained Tan et al;48 Germany Cross-sectional Assessing the impact of infertility on various aspects of psychological function in PCOS women NIH 28.1±4.8 SF-36, SCL-90-R 115 PCOS obtained a major risk factor for psychosocial and emotional problems. Infertility was not a primary determinant of psychological problems Rofey et al;41 USA Interventional Evaluating cognitive–behavioral therapy on psychological problems of PCOS adolescents AES 12–18 SF-36 25 Depressive symptoms and weight decreased significantly Harris-Glocker et al;71 USA Interventional Assessing the effect of treatment (metformin, lifestyle) on the QoL in obese PCOS adolescents NIH 12–18 PCOSQ 36 QoL was improved in both groups (lifestyle and obsessive–compulsive disorder treatment) Ladson et al;72 USA Interventional Assessing the effect of treatment (metformin, lifestyle) on the QoL of adolescents with PCOS NIH 13–18 PCOSQ 28 QoL was significantly improved in both treatment groups Moran et al;73 Australia Case–control Evaluating the psychological features in young girl with PCOS compared with healthy women Rotterdam 18–25 PCOSQ 22 control, 24 PCOS Worsened QoL in PCOS women Thomson et al;34 Australia Interventional Assessing the effect of exercise and dietary restriction on depressive symptoms and HRQoL in obese women with PCOS Rotterdam 29.3±0.7 PCOSQ 104 Dietary restriction, with/without exercise, had similar benefits for improving depression and HRQoL in obese women with PCOS Ladson et al;74 USA Interventional Determining the effect of lifestyle changes (caloric restriction and exercise) on the QoL of PCOS women NIH 29.0±4.5 PCOSQ 114 QoL was improved in emotion and weight areas within each treatment group Bazarganipour et al;75 Iran Cross-sectional Assessing the prevalence of mood disorders and examine predictors for psychological well-being among Iranian PCOS women Rotterdam 15–40 SF-36 300 32% of patients showed elevated anxiety and depression. QoL was very impaired in women with anxiety and depression Bazarganipour et al;76 Iran Cross-sectional Evaluating the effect of different clinical symptoms of PCOS on patients HRQoL Rotterdam 15–40 MPCOSQ 200 Worsened HRQoL in PCOS women was related to more menstrual problems and infertility than to obesity Stener-Victorin et al;77 Sweden Interventional The effect of exercise and acupuncture on the QoL in PCOS women Rotterdam 29.9±4.4 SF-36, PCOSQ 114 Anxiety and depression improved in women treated with acupuncture. HRQoL was improved in both groups Bazarganipour et al;78 Iran Cross-sectional Determining the association between HRQoL and psychosexual variables in patients with PCOS Rotterdam 15–40 MPCOSQ 300 The highest effect of PCOS symptoms on HRQoL was exerted by clinical variables, poor perception, negative body image, and sexual dysfunction De Frène et al;79 Belgium Cross-sectional Investigating the relationship between PCOS symptoms with sexual and relational satisfaction in obese women and their partners Rotterdam 18–43 PCOSQ 62 PCOS characteristics and its concerns were associated with the sexual and/or relational satisfaction of couples McCook et al;28 USA Cross-sectional Investigating the relative contributions of PCOS manifestations to psychological symptoms Rotterdam 18–48 PCOSQ 126 Patients were at a greater risk for depression, anxiety, and interpersonal sensitivity. Menstrual problems predicted every dimension of psychological distress Benetti-Pinto et al;50 Brazil Case–control Assessing the sexual function and QoL in PCOS women Rotterdam PCOS: 26.9±4.9; control: 35.6±7.3 WHOQOL-BREF 102 control, 56 PCOS PCOS women had a worse sexual function and worse QoL in the self-assessment of the health area. Obesity was correlated to the worsening in QoL Guidi et al;80 Italy Cross-sectional Assessing the psychosocial effects of PCOS on adolescents NIH 16–19 PCOSQ 394 Impaired well-being and QoL were found among young females with PCOS Stefanaki et al;81 Greece Interventional The effect of mindfulness – stress program on mental status and QoL in PCOS women Rotterdam 15–40 PCOSQ 73 Stress, anxiety, and depression levels decreased and QoL improved Nasiri-Amiri et al;37 Iran Mixed methods Designing HRQoL measurement tool in Iranian women with PCOS Rotterdam 18–40 PCOSQ-50 200 PCOS, 23 interviews The PCOSQ-50 was a valid and reliable instrument for the assessment of QoL of women with PCOS Shishehgar et al;42 Iran Case–control Comparing the effects of obesity on the HRQoL between women with PCOS and controls AES PCOS: 28.6±4.9; control: 29.0±5.8 SF-36 140 control, 142 PCOS The physical aspects of HRQoL were adversely affected by obesity in both groups, but these impaired effects were greater in PCOS group Huang-TzOu et al;82 Taiwan Interventional Effect of metformin on the QoL of women with PCOS Rotterdam 18–45 WHOQOL-BREF, PCOSQ 109 Metformin improved HRQoL of PCOS women especially in overweight patients Dokras et al;83 USA Interventional Evaluation of the effect of weight loss on mood disorders and QoL in obese women with PCOS Rotterdam 18–40 SF-36, PCOSQ 149 Weight loss result in significant improvements in several physical and mental domains related to QoL Ozcan Dag et al;84 Turkey Case–control Assessment of temperament and QoL in PCOS patients Rotterdam PCOS: 22.6±4.5; control: 21.3±2.1 SF-36 38 control, 53 PCOS PCOS patients had significantly higher rates of depressive and anxious compared with controls. QoL was significantly lower in patients Panico et al;44 Italy Case–control Comparing the QoL in obese and normal weight women with PCOS Rotterdam Controls: 16.4–31; PCOS: 17.2–29 SF-36, PCOSQ, SCL-90-R 80 control, 100 PCOS Worsening of HRQoL in PCOS patients compared with controls Abbreviations: AES, Androgen Excess Society; BMI, body mass index; CHQ-CF87, Child Health Questionnaire-Child Form; FSH, follicle-stimulating hormone; GHQ-28, General Health Questionnaire-28; HRQoL, health-related quality of life; MPCOSQ, Modified PCOSQ; NIH, National Institutes of Health; PCOS, polycystic ovary syndrome; PCOSQ, Polycystic Ovary Syndrome Health-Related Quality of Life Questionnaire; PCOSQ-50, Polycystic Ovary Syndrome Questionnaire; QoL, quality of life; SCL-90-R, Symptom Checklist-90-Revised; SF-36, 36-Item Short Form Health Survey; WHOQOL-BREF, World Health Organization Quality-of-Life-BREF. Table 2 Different components of quality of life in PCOS women Dimensions Studies Psychological and emotional McCook et al,27 Coffey et al,25 Elsenbruch et al,40 Jedel et al,85 Teede et al,3 Månsson et al,86 McCook et al,28 Podfigurna-Stopa et al,62 Weiss and Bulmer,16 Bazarganipour et al,75 Nasiri Amiri et al,87 and Taghavi et al19 Body image Trent et al,66 Ekbäck et al,14 Bazarganipour et al,75 and Taghavi et al19 Social Trent et al,66 Jones et al,23 Schmid et al,24 Ekbäck et al,14 Moran et al,73 Bazarganipour et al,75 Taghavi et al,19 and Weiss and Bulmer16 Sexual Elsenbruch et al,30 Trent et al,66 Tan et al,48 Månsson et al,86 Benetti-Pinto et al,50 and Taghavi et al19 Physical  Weight Barnard et al,33 Hahn et al,43 Elsenbruch et al,30 Kaczmarek et al,32 Trent et al,53 Benetti-Pinto et al,50 and Shishehgar et al42  Hirsutism and acne Elsenbruch et al,30 Ekbäck et al,14 and Khomami et al29  Menstrual problem Bazarganipour et al,36 Bazarganipour et al,75 McCook et al,27 and McCook et al28  Infertility Schmid et al,24 Elsenbruch et al,30 Hahn et al,43 Bazarganipour et al,75 Nasiri Amiri et al,61 and Khomami et al29  Medical Van Wely et al,68 Hahn et al,39 Trent et al,53 Hahn et al,39 Thomson et al,34 Harris-Glocker et al,71 Dokras et al,83 Stefanaki et al,81 and Rofey et al41 Abbreviation: PCOS, polycystic ovary syndrome. Table 3 Most general and specific instruments for assessing HRQoL in women with PCOS Instruments No of items Dimensions covered Studies General instruments  SF-36 36 Physical functioning, vitality/energy, physical role limitation, bodily pain, mental health, emotional role limitation, general health perception, and social functioning Elsenbruch et al,30 Jones et al,23 Van Wely et al,68 Hahn et al,47 Hahn et al,39 Elsenbruch et al,40 Coffey et al,25 Drosdzol et al,60 Ching et al,26 Tan et al,48 Rofey et al,41 Bazarganipour et al,75 Stener-Victorin et al,77 Dokras et al,83 Shishehgar et al,42 Ozcan Dag et al,84 and Panico et al44  SCL-90-R 90 Somatization, obsessive–compulsive, interpersonal sensitivity, paranoid ideation, psychoticism, anxiety depression, phobia, and aggression Elsenbruch et al,30 Hahn et al,47 Hahn et al,39 Elsenbruch et al,40 and Tan et al48  CHQ-CF87 87 Change in health in the last year, role/social emotional, behavioral, physical, bodily pain, behavior, mental health, self-esteem, general health perceptions, family activities, family cohesion, and physical functioning Trent et al,52 Trent et al,66 and Trent et al53  WHOQOL-BREF 26 General health, physical health, psychological, health, Social relationship, and environmental Clayton et al,69 Lipton et al,70 Benetti-Pinto et al,50 and Huang-TzOu et al82  GHQ-28 28 Somatic symptom, anxiety/insomnia, social dysfunction, and depression Ching et al26 Specific instruments  PCOSQ 26 Emotion, hirsutism, infertility, weight, and menstrual problem Cronin et al,21 Wong et al,65 Hashimoto et al,67 Guyatt et al,22 Jones et al,23 Schmid et al,24 McCook et al,27 Coffey et al,25 Ching et al,26 Rofey et al,41 Harris-Glocker et al,71 Moran et al,73 Thomson et al,34 Ladson et al,72 Stener-Victorin et al,77 De Frène et al,79 Stefanaki et al,81 McCook et al,28 Dokras et al,83 and Panico et al44  MPCOSQ 30 Emotion, hirsutism, infertility, weight, menstrual problem, and acne Barnard et al,33 Bazarganipour et al,36 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