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Understanding and Supporting Women with Polycystic Ovarian Syndrome;

A Meta-synthesis

Module Number: PH7013

Programme of Study: Master of Public Study

Assessment Number: J89049

Student Name: Joffy Alex

Module Leader: Jackie Cinnamond

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Declaration
This is to state that my dissertation, titled Understanding and supporting women with
polycystic ovary syndrome - A meta-synthesis, is duly submitted to my department to
complete my degree. The work done here is entirely authentic and performed by me.

The dissertation presented at the university is original, and neither was submitted to any other
universities by me.

Signature - Joffy Alex

Date - 00/00/2022
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Acknowledgment
I would like to acknowledge and thank my lecturer and supervisor for their continued support
and encouragement. My successful completion of this project could not have been
accomplished without their support and my classmates. Thank you all for writing and
researching this project.
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Abstract

PCOS is a metabolic disorder related to hormonal irregularities, associated physiological

symptoms, and comorbidities. The traditional therapeutic approach relied on drugs like
metformin and oral contraceptive pills to normalize estrogen, progesterone, LH, and FSH levels.
However, articles are lacking in the field of psychological distress management.

Aim & Objective – To synthesize evidence on understanding and supporting women with the
polycystic ovarian syndrome.

Methods – To perform the meta-synthesis, relevant published articles in the field of PCOS and
related comorbidities were selected from the Web of science, Pubmed, and Medline, from 2011
to 2022. Citation indices and related keywords are the selection filters for the research effort.
The literature review articles were surveyed following PICO procedures and analyzed following
the process of CASP.

Results - It has been determined that a specific range of symptoms is linked with Polycystic
Ovarian Syndrome, including different problems related to “menstruation and weight difficulties.”
Hirsutism has been reported as the most significant and vital distressing symptom. Compelling
themes are included with the perception regarding symptoms and delays in receiving the
required diagnosis, psychological distress, and practical implication with the existing condition. It
has been seen that coping with the polycystic ovarian syndrome and sufficient perceived needs
is highly required. From the included studies, it has been determined that there is a huge
requirement to provide education among the health care providers and community. A higher risk
of mental health conditions like depression, anxiety, and other conditions is linked to PCOS.
Although minority populations make up roughly 20% of the majority of the samples under study,
ethnic segmentation was rarely undertaken, making it challenging to understand the mental
illness impact of PCOS on various cultures.

Conclusion – PCOS is an associative and multifactorial disorder and requires an attentive

addressing process for the affected individuals. The hormonal irregularities are related to
metabolic disorders, converging into hyperinsulinemia, hyperandrogenemia, and dyslipidemia in
PCOS-positive individuals. Women with PCOS have experienced high psychological distress
and other difficulties with their condition. Suggestive efficient strategies to decrease the negative
psychological impact include education at several levels. To maximize the total clinical care
provided to these patients, it is crucial to regularly and carefully examine the most recent
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research. The accompanying complexities have an impact on clinical practice as well as access
to the healthcare system. Therefore, healthcare practitioners working in primary and secondary
care settings should access cultural appropriation-based training.

Keywords – polycystic ovarian syndrome (PCOS), Pregnancy, Hirsutism, psychological

counseling, quality of life, well-being, multi-ethnic
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Table of Contents
Declaration.....................................................................................................................................2

Acknowledgment...........................................................................................................................3

Abstract..........................................................................................................................................4

CHAPTER 1.................................................................................................................................10

Introduction..................................................................................................................................10

Background..................................................................................................................................10

Research rationale......................................................................................................................12

Structure of the work...................................................................................................................12

Knowledge gap............................................................................................................................13

Research Objectives...................................................................................................................13

The research aims and objectives of this study are:................................................................13

CHAPTER 2.................................................................................................................................14

Literature Review.........................................................................................................................14

Metabolic Syndrome in women with PCOS..........................................................................15

Understanding the Psychological state of women with PCOS.............................................16

Emotional support to women with PCOS.............................................................................18

Existing clinical support for the PCOS patients....................................................................19

Necessities of Educational support for women with PCOS..................................................20

Increase risk and development of cardiovascular disease in women with PCOS................21

Gestational diabetes and other pregnancy-related issues due to PCOS.............................22

CHAPTER 3.................................................................................................................................24

Methodology................................................................................................................................24

Search Strategy....................................................................................................................24

Eligibility Criteria...................................................................................................................24

Data Extraction.....................................................................................................................25

Quality Assessment..............................................................................................................25
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Reason for Considering Qualitative Data.............................................................................26

Reason for Considering Qualitative Data Analysis...............................................................26

Significance of Qualitative Data Analysis in the Context of this Research...........................27

Used types of Qualitative data analysis in this Research.....................................................27

Grounded Theory analysis...................................................................................................28

Paradigm (Philosophical Stance).........................................................................................28

Research Philosophy...........................................................................................................28

Advantages of Naturalism Research Philosophy.................................................................29

Disadvantages of Naturalism Research Philosophy............................................................30

Ontology...............................................................................................................................30

Epistemology........................................................................................................................32

Axiology................................................................................................................................33

CHAPTER 4.................................................................................................................................37

Results.........................................................................................................................................37

Characteristics of the participants........................................................................................38

Psychological Health Impacts of PCOS on Women.............................................................39

Major Depressive Disorder...................................................................................................39

Elevated Existing Disorder...................................................................................................40

Anxiety among Women with PCOS......................................................................................41

Common Mental Health........................................................................................................42

CHAPTER 5.................................................................................................................................44

Discussion...................................................................................................................................44

CHAPTER 6.................................................................................................................................51

CONCLUSION AND LIMITATIONS............................................................................................51

Conclusion............................................................................................................................51

Limitations............................................................................................................................52

References..................................................................................................................................53
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Appendices..................................................................................................................................60

Appendix A..................................................................................................................................60

List of Included Journals.......................................................................................................60

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List of Figures

Figure 1: Physiological and Psychological complications due to PCOS (Bazarganipour et al.,

2013)............................................................................................................................................17
Figure 2: Flow chart for the selection process and literature search...........................................37
Figure 3: Characteristics of the Participants (Source: Hadjiconstantinou et al., 2017)...............39
Figure 4: Major Depression by Region........................................................................................40
Figure 5: Elevated Existing Depression by Region.....................................................................41
Figure 6: Anxiety Prevalence by Region.....................................................................................42
Figure 7: Common Mental Health Disorders...............................................................................43
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CHAPTER 1

Introduction
The polycystic ovarian syndrome is one of women's most common endocrine conditions
(McCartney & Marshall, 2016). It has significant consequences regarding both mental and
physical health. It enhances the risk of type 2 diabetes mellitus, cardiovascular disease,
hypertension, as well as being involved in comprehensive poor well-being. Collected studies
have highlighted the consequences of managing polycystic ovarian syndrome (PCOS).
Insufficient information given to women diagnosed with polycystic ovarian syndrome may also
generate confusion regarding the cause of experiencing different symptoms, leading to feelings
of guilt and insufficient control (McCartney & Marshall, 2016). NIH, and AE-PCOS society
(Androgen Excess & PCOS Society) criteria, the most accepted phenotypic forms could be
divided into four types; Excess androgen production, ovulatory dysfunction; Excess androgen
production and diagnosis of PCOS; Dysfunctional ovulation and PCOS character state
expression; and Excess androgen production, ovulatory dysfunctions, and etiology of PCOS
(Wolf et al., 2018). It has been clear that a diagnosis of PCOS has significant psychological
issues. Still, very few considerations have been provided to more practical implications relating
to daily living and to the process of supporting women with the condition (Setji & Brown, 2014).
The primary objective of this dissertation is to confirm the collected findings in an “ethnically
diverse population “and to enlarge the scope of current knowledge related to required support
and experience. On a practical level, this study has specifically focused on revealing the
“potential acceptability of group education sessions for women with polycystic ovarian
syndrome” to provide the significance of this education Programme.

Background
A wide variety of factors does influence the disease prevalence within the population,
with differences in cultural backgrounds and ethical upbringing (Wolf et al., 2018). Polycystic
ovarian syndrome is one of the chronic disorders that affect women of reproductive age,
diagnosed by the presence of the following two factors such as disruption of the menstrual cycle
and small ovarian cysts, as well as clinical signs of hyperandrogenism (Wolf et al., 2018). Few
women may have polycystic ovaries without any symptoms. In this case, these women are
presented as having polycystic ovaries without any syndrome. Hyperandrogenism is the
condition of hormonal disturbance that has the ability to produce a number of clinical
manifestations in women, including weight gain or obesity, fertility issues, alopecia, hirsutism, as
well as acne and mood changes. Despite the common endocrinopathy disorder, it has been
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believed to affect approximately “6-10% of reproductive-age women” (Wolf et al., 2018).

Although this condition is incurable, treatment can include a massive change in lifestyle and
efficient surgery can help manage different individual symptoms. Women with this disease have
an enhanced risk of creating other health complications such as cardiovascular disease,
endometrial cancer, type 2 diabetes mellitus, and stroke. Without these, women with PCOS can
also have a severe risk of complications during pregnancy in the condition of obesity (Wolf et
al., 2018).

It has been mentioned in the above section that women with PCOS suffer several
issues, such as physical and mental health complications. In this condition, a good lifestyle and
mental support are necessary for these patients. This research has focused on addressing the
psychological and physical issues of women with PCOS with proper understanding and
supporting them mentally by implementing educational programs (Azziz et al., 2016). It has
been confirmed that PCOS's occurrence depends on both lifestyles and genetic reasons (Setji &
Brown, 2014).

Research by Jayasena and Franks in 2014 stated that polycystic ovarian syndrome is
one of women's most common endocrine disorders (Jayasena & Franks, 2014). This disease
primarily affects women of each ethnicity and race “who are of reproductive age.” It has been
found that 5 to 10% of women between 15 and 44 are mostly affected by PCOS. In this range of
age, most women are affected in their 20 to 30 age group causing them to have difficulties in
getting married. Also, Jayasena and Franks’ research has stated that PCOS can happen at any
time after puberty.

Another research by McCartney and Marshall in 2016 stated that there is currently no
specific way to cure a patient with “polycystic ovarian syndrome''. It is only possible to manage
different symptoms of PCOS (McCartney & Marshall, 2016). In 2020, a ground-breaking study
published in the “Journal Nature of Medicine'' can be used to find specific treatments for this
disease. Dr. Paolo Glacobini led this study at the “French National Institute of Health and
Medical Research” (Bednarska & Siejka, 2017).
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Research rationale
Psychological research has “largely centered on the psychosocial impact of PCOS” and
it is quite surprising. This condition has been given the scope of different health complications
along with unpleasant physical manifestations (Bednarska & Siejka, 2017).

PCOS and its related symptoms are associated with “poorer quality of life” and
enhanced psychological distress in women with this disease (Azziz, 2018). It has been seen
from the measurement of psychosocial distress that women having hirsutism have shown a
massive score for depression and anxiety in contrast to patients who had been “newly
diagnosed with breast or gynecological cancers” (Bednarska & Siejka, 2017). The treatment
system facilitates various approaches. PCOS-affected women need a more intensive care
system that includes counseling to enhance their psychological condition and life-style quality of
the individuals. Due to these issues of women with PCOS, it is essential to establish evidence
on understanding and supporting them to achieve stable mental and physical health.

Structure of the work

The research procedure will try to synthesize the existing fatalities and treatment
procedures to highlight the gaps and areas where further development can be achieved. The
introduction portion circumnavigates the highlighting of the overview of the research area. The
relatedness of PCOS and other associated disorders are being described with an outlook for the
most prevalent symptoms and their effects on women's health. The literature review has been
performed through the PICO process and analyzed through the CASP process to demonstrate
the relevance and credibility of the articles with the research procedure related to PCOS. The
methodology portion will highlight the ontological, epistemological, and axiological points of the
most valued articles about the research effort. Ethical considerations have been noted while
collecting the relevant data to be evaluated to analyze the research outcome. The discussion
portion deals with critical perception about the outcomes of the research efforts and both
beneficial and detrimental terms of the previous efforts upon the livelihood of women.
Necessary statistical implementation is carried out when the justification of a claim is needed.
The most effective therapeutics have been noted.
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Knowledge gap
To date, there is no specific treatment to cure PCOS disorder. Approximately 95% of
studies have shown the significance of medical treatment in women with PCOS. Furthermore,
only a few studies have mentioned the psychological stress of women during their pregnancy
with PCOS. This is the large gap in knowledge of understanding and supporting women with
PCOS. Based on this gap, this research study will evaluate the significance of understanding
and supporting women in medical treatment, mental and other ways. Different previously
published papers have been collected to make a concept and evaluate the significance of
supporting and understanding women with PCOS disorder. Beside this, this entire paper is
going to evaluate the importance of educational program in women with PCOS.

Research Objectives
The research aims and objectives of this study are:

I. To synthesize evidence on understanding and supporting women with polycystic ovarian

syndrome.
II. To provide an adequate education program to create awareness of women's polycystic
ovarian syndrome.
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CHAPTER 2

Literature Review
Polycystic ovary syndrome (PCOS) is a common endocrine disorder among women of
reproductive age owing to certain genetic and environmental factors (Azziz et al., 2016; Aversa
et al., 2020). The literature on the subject evolved over the years to accurately define and
explain the complex syndrome of PCOS (Clark et al., 2014; Teede et al., 2018; Azziz et al.,
2016). Various studies associate PCOS with multiple reproductive and psychological
complications for women (Banting et al., 2014; Deswal et al., 2020). The manifestations of
PCOS include menstrual irregularities, excess androgens, hirsutism, and excess weight.
Evidence from studies reports a strong association of PCOS with obesity, especially abdominal
adiposity and type 2 diabetes (Morgan et al., 2012; Ates et al., 2017; Zahiri et al., 2015).

Previously, the National Institute of Health (NIH) considered hyperandrogenism and

chronic anovulation as the two main clinical signs to diagnostically identify PCOS in women
(Zawadzki and Dunaif, 1992), excluding the ultrasonographic evidence, which was otherwise
considered a definitive marker for PCOS. The ultrasound technique was considered the most
prevalent diagnostic technique to minutely capture the outer and inner details of the ovaries
using morphological studies reporting the prevalence of detection of polycystic ovaries from 17
to 33% (Pasquali et al., 2011). In 2003, the European Society for Human Reproductive and
Embryology/American Society for Reproductive Medicine (ESHRE/ASRM), commonly known as
the Rotterdam consensus, revised the diagnostic criteria for PCOS from its previous criteria of
1999 by specifying hyperandrogenism and polycystic ovary morphology as two key features
apart from chronic anovulation. The consensus meeting produced a definition of PCOS along
with the morphology of a polycystic ovary, defined as an ovary with 12 or more follicles
measuring 2–9 mm in diameter and increased ovarian volume (>10 cm3) (Pigny et al., 2003).
The Rotterdam consensus further identified four different and unique phenotypes to clinically
identify the different PCOS conditions in women (Clark et al., 2014). Later, the Androgen
Excess Society (AES) proposed the criteria to define PCOS as mainly a condition of abnormal
androgen production wherein PCOS is diagnosed as the combined presence of androgen
excess in the form of hirsutism and hyperandrogenism and evidence of ovarian dysfunction in
the form of oligoanovulation and polycystic ovaries (Williams et al., 2018).

Globally, the prevalence of PCOS, estimated by NIH Report, is around 6 to 10% across
Asia, Europe, Australia, and America (Deswal et al., 2020). The prevalence of PCOS in women
is estimated to be 7% using the NIH criteria, 15.2 % using the ESHRE/ASRM criteria, and
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7.92% using the AES criteria, showing the prevalence of PCOS varies based on the criteria
used (Deswal et al., 2020).

Metabolic Syndrome in women with PCOS

PCOS poses a significant socio-economic burden to healthcare as statistics show that it
affects 4% to 20% of women of reproductive age globally (Deswal et al., 2020). However, it is
not yet considered a public health problem of concern because diagnosis, prevalence, clinical
practices, etiology, prevention, and associated psychological issues are the most confusing
aspect of PCOS (Deswal et al., 2020). Several studies associate PCOS with the development of
metabolic syndrome (MetS) due to its manifestations, such as hyperandrogenism, obesity, and
insulin resistance (IR) (Zahiri et al., 2015; Ates et al., 2018; Fazlee et al., 2018). Their research
explained that some women with PCOS can develop a condition known as metabolic syndrome,
which refers to a condition of endocrine disturbances leading to conditions like insulin
resistance, dyslipidemia, obesity and central adiposity and hypertension, which can advance to
an increased risk of cardiovascular diseases and type 2 diabetes (Ates et al., 2018). Abdominal
obesity is indicated to be the most common predictor of metabolic abnormality in PCOS (Moran
& Teede, 2009), and hyperandrogenism and insulin resistance form the metabolic hallmark of
PCOS women (Kamalnathan et al., 2013).

Ates et al., 2018 studied the metabolic and clinical characteristics of 77 Turkish
adolescent girls with PCOS to understand the prevalence of metabolic syndrome. Among the
participants, 13% of adolescents with PCOS had MetS, while the control group did not report
any metabolic syndrome, concluding a higher prevalence of MetS in adolescents with PCOS.
This finding was reinforced in a study by Zahiri reporting an even higher prevalence, that is,
28.8% of MetS in women with PCOS assessed in 215 Iranian women with PCOS (Zahiri et al.,
2015). Likewise, Fazleen and others, in a meta-analysis, derived that the odds of experiencing
MetS in PCOS groups were 2.69 times more than girls without PCOS (Fazleen et al., 2018).

Indeed, genetic and metabolic factors play a role in the advancement of PCOS. Women
with PCOS suffering from obesity predispose them to metabolic syndrome, as visceral obesity is
a common feature identified in women suffering from PCOS and metabolic syndrome
simultaneously (Fazleen et al., 2018). Several studies discuss the association of obesity in
women with PCOS, implying that PCOS could be more prevalent among women who are
overweight and obese and making the consequences of symptoms more severe to an extent
(Lim et al., 2012; Breyley-Smith et al., 2022). An estimated 35% of women with PCOS present
themselves as overweight or obese, with higher Body Mass Index (BMI), and 28% of overweight
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and obese women were diagnosed with PCOS in a study in Spain, related to increased severity
of symptoms such as hirsutism (Breyley-Smith et al., 2022; Alvarez-Blasco et al., 2011).

In adolescent girls with PCOS, early identification of metabolic disorders could provide
an opportunity to reduce the long-term health consequences of PCOS (Ates et al., 2017). The
analysis of 9 studies specified that screening PCOS at an early age is essential to prevent MetS
and its complications leading to morbidity and mortality in later life (Fazleen, 2018). The Rees et
al. (2016) study stated that younger women with PCOS have reduced fertility. However, after
diagnosis, the fertility rates may be restored. The research further confirmed the adverse effects
of PCOS on several pregnancy outcomes, including gestational diabetes, pre-eclampsia, and
preterm birth, independent of obesity (Rees et al., 2016).

Understanding the Psychological state of women with PCOS

Along with the clinical manifestations, psychological consequences have been linked to
PCOS symptoms in women suffering from it (Hadjiconstantinou et al., 2017; Zahiri et al., 2015).
The study by Lathia et al. (2022) observed mental illness in about 32% of women with PCOS,
among which around 5% were severely affected with depressive and anxiety disorder.

The study by Bazarganipour et al. (2015) showed that the presence of PCOS in women
leads to a reduction in Health-related quality of life (HRQOL). HRQOL by World Health
Organization (WHO) is the most commonly used self-reported measure of the subjective
perception of well-being by patients. This finding was corroborated by Behboodi Moghadam et
al. (2018) with a study on 200 PCOS women in Iran using the Persian version of the Health-
related Quality of Life Questionnaire for PCOS (PCOSQ) to measure their quality of life. The
findings showed that impairment of quality of life was associated with PCOS-related conditions
such as hirsutism, infertility, and menstrual problems (Behboodi Moghadam et al., 2018). These
conditions are attributable to the biochemical and hormonal imbalances associated with PCOS,
physiological changes, poorer mental health outcomes, and worsened quality of life
(Bazarganipour et al., 2015; Behboodi Moghadam et al., 2018; Lathia et al., 2022). Additionally,
Berni et al. (2018) attributed fertility complications being the primary cause of mental morbidity
among young women (Berni et al., 2018).

Further, Banting et al. (2014) stated that PCOS is associated with an increase in
physiological impairments like reproductive issues and cardio-metabolic issues and subsequent
illness, leading to a lower psychological state in women and mental health differences being
noticed in adolescents in different PCOS phenotypes (Banting et al., 2014). Furthermore, using
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self-report measures, women with untreated PCOS were analyzed for at-risk patients for
psychiatric disease and emotional distress. On the other hand, Elsenbruch et al. (2006)
research recognized majority of patients exhibit subclinical levels of psychological disturbances
and emotional distress together with obesity leading to a decline in their quality of life,
highlighting that psychiatric illness may go undetected in a proportion of PCOS patients
(Elsenbruch et al., 2006). The “International Evidence-based guidelines for PCOS management”
address some of these concerns and advocate for psychological screening of patients with
PCOS (Tedee et al., 2018).

Figure 1: Physiological and Psychological complications due to PCOS (Bazarganipour et al.,

2013)

Recognizing the impact of these psychic issues, Tay et al. (2019) research reported that
one in five women with PCOS is likely to develop particular types of psychic issues like perinatal
mental disorder during pregnancy, causing a negative impact on the women as well as the
offspring (Tay et al., 2019). Their study indicated that the short-term effects of perinatal mental
disorder are low birth weight and poor bonding between the mother and the infant and is
associated with postnatal depression and postnatal anxiety (Tay et al., 2019).

For the management of PCOS, studies have found an association between physical
activity with lower levels of depression in women with PCOS and the mental health benefits of
staying physically active (Banting et al., 2014; Bazarganipour et al., 2013). These studies further
recommend that it is imperative to consider prescribing physical activity to women suffering from
psychological issues due to PCOS during the individualized PCOS management by healthcare
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providers and consider both common and PCOS-specific barriers and motivators for successful
engagement (Banting et al., 2014). The authors mention that the first-line management strategy
of PCOS includes lifestyle management through dietary intervention and scheduled physical
activities being fruitful in managing PCOS in women of all ages, effectively reducing depressive
symptoms and improving quality of life (Bazarganipour et al., 2013).

It is widely observed that relatively less attention is paid to the symptoms of PCOS and
the treatment of associated mental health conditions. Based on the evidence shared, it is clear
that the psychological impact of PCOS on women is of great magnitude and needs appropriate
attention in the management of PCOS.

Emotional support to women with PCOS

Considering the physiological and psychological impact of PCOS, the social and
emotional needs of women and adolescents with PCOS are inadequately understood and
recognized (Dowdy, 2012). This is especially important for adolescents suffering from PCOS as
they tend to face social isolation, social anxiety, issues with body image and perception,
bullying, and cultural factors playing a role in impacting their self-esteem (Dowdy, 2012).

Some studies identify that support groups may be beneficial to PCOS patients suffering
from chronic conditions and help them improve their quality of life (Roessler et al., 2012;
Holbrey & Coulson, 2013), and support through groups helps provide detailed and personally
relevant information to women living with PCOS (Roessler et al., 2012). The evidence suggests
that women participating in support groups find it useful to reduce the negative psychosocial
impact of PCOS and other fears like infertility (Domar et al., 2000; Percy et al., 2009). In this
aspect, Roessler et al. (2012) examined the psychological impact of a group-oriented approach
to disease management and health behavior in women with PCOS. They concluded that group
counseling sessions focusing on supportive relationships followed by high-intensity aerobic
training have beneficial effects on overall well-being covering physical and mental health
(Roessler et al., 2012). Other authors observed that participation of women with PCOS in
support groups is beneficial in minimizing their psychological distress as it helps in decision-
making with physicians (Percy et al., 2009; Holbrey & Coulson, 2013).

Given the increased use of online communication, social platforms on the internet is
another place for peer-to-peer online support groups for adolescents with PCOS to help them
cope with their disturbed psychic state (Dowdy, 2012; Mousiolis et al., 2012). Peer-to-peer
support empowers adolescents to improve their quality of life through exchanging relevant
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information, sharing experiences, providing emotional support and recognition, helping, and
amusement (Holbrey & Coulson, 2013). Some positive and empowering outcomes include
building positive relationships with physicians and cooperating in treatment, disease
acceptance, a feeling of confidence, optimism, and improved self-esteem and well-being
(Mousiolis et al., 2012; Holbrey & Coulson, 2013). The involvement of motivational interviewing
and strength-based counseling can help support PCOS patients to recognize their ambitions
and strengths emotionally and empowering them to deal with their emotional distress and mood
disorders and improve their self-esteem.

Therefore, from the evidence shared, it can be inferred that group interventions in the
form of support groups and online peer-to-peer groups result in significant positive psychological
outcomes for women and adolescents suffering from PCOS by providing an emotional anchor to
them in dealing with the symptoms and fears.

Existing clinical support for the PCOS patients

The international evidence-based guideline by the Australian National Health and
Medical Council (NHMC) for the assessment and management of PCOS specified that the
majority of evidence with respect to the assessment and management of PCOS is generally of
low to moderate quality. More research is required, especially on refining the diagnostic features
of PCOS (National Health and Medical Research Council, 2018). Overall, the guidelines are
comprehensive and provide a total of 31 evidence-based recommendations, 59 clinical
consensus recommendations, and 76 clinical practice points related to the assessment and
management of PCOS, providing precise and reliable information to the clinicians and health
care providers to optimize diagnosis, assessment, and management of PCOS (National Health
and Medical Research Council, 2018).

The NHMC outlines some of the critical changes in the guideline, which include
refinement of the diagnostic criteria focussing on improving the accuracy of diagnosis, reduction
in needless testing, recommending a focus on different lifestyle modifications, education,
improving the emotional wellbeing and quality of life, and lastly emphasizing the importance of
evidence-based medical therapy and affordable and safer fertility management (National Health
and Medical Research Council, 2018).

Several studies identify that PCOS leads to a multitude of issues in women suffering
from it and necessitates elevation from symptoms. Due to the unavailability of definitive
therapeutic treatments, the situation aggravates the patients. The clinical management must
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start with comprehensive history taking and physical examination for symptoms and signs of
clinical hyperandrogenism, including acne, alopecia, and hirsutism. In adolescents, severe acne
and hirsutism (Tedee, 2018). The healthcare providers must be kept updated on several areas
of concern regarding PCOS and facts like PCOS impacting body image and emotional distress,
lowering the quality of life. Hirsutism and irregular menstruation are some other areas of
concern requiring appropriate management (Bazarganipour et al., 2015). The guidelines
recommend lifestyle interventions, including diet and physical activity in all women with PCOS
with excess weight for weight management, abdominal adiposity and insulin resistance (Tedee,
2018). In adolescents and adult women, lifestyle improvement, especially weight loss, can be
beneficial in managing PCOS symptoms (Pfieffer, 2019). The particular symptoms and issues in
PCOS are targeted through combination drug therapy based on various factors.

One of the significant evidence-based recommendations is using combined oral

contraceptive pills (COCPs) for adult women and adolescents with precise diagnosis of PCOS
to manage hyperandrogenism and irregular menstrual cycles (Pkhaladze, 2021). In women
where lifestyle modifications do not achieve the desired results, metformin in combination with
the COCPs is recommended for the management of hormonal and metabolic outcomes as
metformin acts like an insulin sensitizer drug (Fornes et al., 2022), and metformin controls the
insulin level by increasing androgens activity (Tedee et al., 2018).

Anti-androgen pharmacological agents can be used to treat hirsutism or for treating

androgen-related alopecia in combination with COCPs. They can be used effectively in cases
where COCPs are contraindicated or poorly tolerated, along with other forms of contraceptives
(Goodman et al., 2015). Flutamide is another group of drugs that mitigates hirsutism issues
(Goodman et al., 2015). Gonadotrophins are used as the second medicine of pharmacological
agents in women with anovulatory infertility after the oral ovulation induction therapy has failed
and if available and affordable. It is recommended to use gonadotrophins in preference to
clomiphene citrate combined with metformin therapy for ovulation induction to improve
ovulation, pregnancy, and live birth rates (Abu Hasim et al., 2015).

Necessities of Educational support for women with PCOS

As discussed in previous sections, women with PCOS experience physiological and
psychological distress governing several aspects of women's lives, making it highly essential to
provide them education and create awareness of the different aspects of PCOS to reduce the
negative psychological impact on women’s quality of life (Hadjiconstantinou et al., 2017). The
HRQOL score is found to be better with an increasing level of education in women (Tabassum
 21

et al., 2021). Apart from this, nutrition education, promoting nutritional awareness and strategies
helps in weight management in overweight and obese patients, helping improve general health
parameters (Behboodi Moghadam et al., 2018). At the same time, it is important to educate their
families about the disease, symptoms, medications, lifestyle modifications and dietary
interventions to ensure support (Holbrey & Coulson, 2013).

The dilemma associated with PCOS is consistently underestimated. Fear of infertility is

one of the leading causes of mental and emotional distress as infertility is considered negative
to women's character in many societal perspectives. Education and awareness about PCOS
and its complications are essential to curtailing such social beliefs (Tabassum et al., 2021).
Patients suffering from severe depression and anxiety disorder risk committing suicide (Lathia et
al., 2022). Pfieffer (2019), in an updated document on PCOS, suggests that education must
form a large part of primary care visits, especially for PCOS patients. Many of the risks
discussed are preventable and can be addressed. Education and the correct information can
play a significant role in helping patients make necessary modifications (Pfieffer, 2019). Further,
if patients are aware, it can help them analyze their health status through self-directed care and
monitoring. However, worldwide there is a severe lack of awareness among women on
reproductive issues (Pfieffer, 2019).

Overall, educational support and support by social groups and families can provide an
early intervention to induce better knowledge on needed lifestyle changes to improve women's
health and quality of life. It is necessary to educate the patients about behavioral strategies
throughout their lifespan as the severity of the disease will ease the symptoms (Pfieffer, 2019).
Indeed, it has been observed that physically fit PCOS patients are estimated to have improved
ovarian function with a regular ovulation rate and prevent the development of metabolic
syndrome (Pfieffer, 2019).

Increase risk and development of cardiovascular disease in women with PCOS

Studies identify increased risk and development of cardiovascular disease as a long-
term outcome of PCOS status in women and its association with dyslipidemia, including high
triglycerides and total cholesterol (Pasquali et al., 2011). Chronic anovulation, a characteristic of
PCOS, is an essential mechanism for increased CVD risk (Dilbaz et al., 2011).

The International evidence-based guideline for the assessment and management of

PCOS recommends that all women with PCOS must be screened and assessed for
cardiovascular risk factors that are cigarette smoking, high blood pressure, impaired glucose
 22

tolerance, excessive alcohol consumption, dyslipidemia, lack of physical activity and after that
evaluated for their increased risk of cardiovascular disease (CVD) (National Health and Medical
Research Council, 2018).

Gestational diabetes and other pregnancy-related issues due to PCOS

As a metabolic disorder, PCOS has been established to cause insulin resistance and
increase the risk of type 2 diabetes (Morgan et al., 2012). Insulin resistance is directly related to
pregnancy, which is the primary pathogenic mechanism that leads to the development of
gestational diabetes mellitus (Cioana et al., 2022).

Kamalnathan et al. (2013) estimated that a significant section of lean women with PCOS
have a baseline intrinsic insulin resistance. However, those with superimposed obesity have
additional insulin resistance from the excess adipose tissue. The baseline insulin resistance
seems to be exacerbated with entry into pregnancy; therefore, there is an increased risk of
pregnancy complications in women with PCOS. The authors estimate that PCOS affects 6 to
15% of women of reproductive age from 15-45 years, and pregnancy in women with PCOS is
integrated with induced risk of gestational diabetes mellitus (Hadjiconstantinou et al., 2017;
Cioana et al., 2022). This could lead to adverse maternal and offspring outcomes due to its
association with increased risk of miscarriage, preterm delivery, hypertensive disorders of
pregnancy, and birth of small for gestational age new-born (Kamalnathan et al., 2013;
Hadjiconstantinou et al., 2017).

Further, in a study on Turkish adolescents, the serum levels of cholesterol levels and
fasting glucose levels did not differ in the study group and control group. In contrast, the levels
of total triglycerides, fasting insulin, and homeostasis model assessment of insulin resistance
(HOMA-IR) were significantly higher in the PCOS group compared with controls corroborating
the association of type 2 diabetes with PCOS (Ates et al., 2017). Fornes et al. (2022), in the
population-based cohort study on the Swedish population found that women with PCOS without
metformin were associated with a higher risk of cesarean section deliveries, preeclampsia and
gestational diabetes compared to women without PCOS without metformin use (Fornes et al.,
2022). On the other hand, Adebisi et al. (2021) argued that a physiologic "insulin insensitivity"
occurs at the time of pregnancy due to the secretion of placental hormones. These hormones
are highly responsible for the induction of nutrient utilization by the fetus (Adebisi et al., 2021).

However, general perinatal guidelines do not recognize PCOS as a risk factor, and the
international evidence-based PCOS guideline noted inadequate evidence in this area. This gap
 23

in literature needs to be addressed and highlights the need to screen for common perinatal
mental disorders in women with PCO (Tay et al., 2019). Rees and other authors stressed the
need for intensive monitoring of women with PCOS during pregnancy. They emphasized the
need for more studies to understand better mechanisms by which these complications arise
(Rees et al., 2016).
 24

CHAPTER 3

Methodology

The methodology collects specific procedures and techniques used to identify, select,
process, and analyze information about the topic (Leary & Walker, 2018). In this research, a
qualitative metasynthesis research method was utilized throughout the research. The qualitative
metasynthesis approach was used to analyze data across qualitative studies around the
research topic. The methodology identified specific research questions, and the relevant
qualitative evidence was searched, selected, summarized, and combined to address the
research question (Leary & Walker, 2018).

Qualitative data analysis has been followed to rigorously analyze each collected data for
this research. This qualitative data analysis is performed by considering each area of the
collected data (Leary & Walker, 2018). This qualitative data analysis made it easy to interpret
and evaluate all of the data to achieve a meaningful result (Leary & Walker, 2018).

Search Strategy

To perform the metasynthesis, a systematic computer-assisted literature search of

relevant published articles in the field of PCOS and related comorbidities was selected from
Web of Science, Pubmed, and Medline, from 2011 to 2022 (Deswal et al., 2020). Kew words
were used to search for the relevant materials. The search strategy used a combination of
different keywords such as “prevalence of PCOS,” “Understanding women with PCOS,”
“Supporting women with PCOS,” “Managing PCOS among Women,” “Programmes for women
with PCOS,” and “Public awareness on PCOS,” and “Polycystic ovary syndrome. For additional
research, the references in the selected studies were further investigated. The literature review
articles were surveyed following PICO procedures and analyzed following the process of CASP.

Eligibility Criteria
Inclusion Criteria

Studies that met the following criteria were included:

I. Cohort research, Case-control, and cross-sectional studies including PCOS women in

their reproductive years and age-matched of any ethnicity.
II. Independent studies that contain original data.
 25

III. Studies containing secondary data

IV. The publication is written in English. This is because the researcher could only read and
understand English.

Exclusion Criteria

Studies were excluded if;

I. The study contained data that overlapped with other research studies.
II. The study was reported in a language other than English.
III. Not fully published in peer-reviewed journals.
IV. Published articles with limited access.

The inclusion and exclusion criteria helped filter the only research studies that contained
information relevant to the research topic. The exclusion of journals published with limited
access may limit the access to essential publications that could offer vital information for this
study.

Data Extraction

Data retrieved for the research included the authors' name, publication year, study design,
country of research, criteria for diagnosing PCOS and MetS, the sample size for controls and
cases, and the age of the participants.

Quality Assessment

The comprehensive quality of the collected data was assessed by utilizing the “Quality
Assessment for Studies of Diagnostic Accuracy” (QUADA) tool. The checklist of the quality
scoring is included with the following statement:

I. Size of the sample

II. Clear objective
III. Inclusion and Exclusion criteria
IV. Adequately study design
V. Diagnostic methods of PCOS
 26

Reason for Considering Qualitative Data

Qualitative data allows a researcher to explore ideas based on research participants'

views and further explain the quantitative results (Akinyode & Khan, 2018). In this research,
metasynthesis is the core research method. The metasynthesis approach utilizes qualitative
data to establish new interpretations of this research (Deswal et al., 2020). Therefore, qualitative
data is essential for successful metasynthesis in this research. This research will analyze data
across qualitative studies around the research topic.

Reason for Considering Qualitative Data Analysis

Qualitative data analysis deals with the determination of gathered data to find the
relationship between them. Identification of this relationship helps to learn a brief knowledge of
the selected topic (Akinyode & Khan, 2018). This process helps to solve any problems related to
the topic. After this process, all the collected data has been analyzed and interpreted to achieve
a meaningful connection to develop a relationship among different "textual data formats." After
that, this analysis method helps to identify the patterns and other themes of the data to get a
considerable result (Akinyode & Khan, 2018). In the context of this research, the overall process
of qualitative data analysis has helped answer every research question correctly. It has been
seen that qualitative data analysis alleviates the comprehensive work of "data interpretation."
The overall result is drawn out from the textual format of the collected data. One of the
significant advantages of this method is that the analysis method works throughout the "analysis
process of the data" (Akinyode & Khan, 2018).

This qualitative data analysis is a cyclic and continuous process along with the process
of data evaluation. In the context of this research, this qualitative data analysis has been
selected to draw a meaningful connection and relationship between previous studies (Akinyode
& Khan, 2018). Due to the selection of qualitative data analysis, I keenly observed the occurring
pattern in the data formats. It is one of the significant steps in qualitative data analysis
(Akinyode & Khan, 2018).
 27

Significance of Qualitative Data Analysis in the Context of this Research

Based on the selected topic, it was crucial to know different specific studies to make
meaningful sense of the topic (Kuckartz, 2019). The selection of this qualitative data analysis
has helped to know the frequency of traits and different characteristics of different data cases
(Kuckartz, 2019).

This data analysis method's selection has helped create data parameters to extract more
extensive data sets. After that, these data sets were observed through qualitative data analysis
(Kuckartz, 2019). This specific data analysis type has helped collect data sets for the
"quantification process." From this phenomenon, it has been realized that "qualitative data is the
base of quantitative data" (Kuckartz, 2019, p. 15).

Qualitative data has played a significant role in researching women of different

geographical regions (Kuckartz, 2019). It can be said that qualitative data is about the emotions
and perceptions of people that are involved in the analysis. This similar perception is considered
in quantitative data analysis, where it gets "documented for future research."

Used types of Qualitative data analysis in this Research

There are five different types of qualitative data analysis. These are content analysis,
narrative analysis, discourse analysis, framework analysis, and grounded theory analysis.
Among these five types, three types of qualitative data analysis have been followed while
conducting this research (Kuckartz, 2019). This is because the narrative analysis centralizes on
analyzing information through stories or narration by an involved participant, which is not the
case in this research study. Any study published in other languages other than English was
excluded from this study, and therefore discourse analysis was not utilized

Content Analysis

Through this analysis, all the data is categorized based on the verbal and behavior
standards of the data. This work has been done by summarizing and classifying the collected
data (Kuckartz, 2019). It has been determined that this analysis is entirely based on the content
of the collected data. This analysis has been performed based on the collected data,
relationships, and collected data patterns (Kuckartz, 2019).
 28

Framework Analysis

This type is one of the advanced forms of qualitative data analysis. Through this type, all
the contents are properly studied to make the overall relationship among collected data
(Kuckartz, 2019). In the context of this research, this analysis type was included with the
framework, familiarization, charting, mapping, and interpretation. This analysis has been
performed through an accurate channel system that frames the complete research work
(Kuckartz, 2019).

Grounded Theory analysis

Through this type of analysis, a single case of a woman with polycystic ovarian
syndrome was considered to make up the complete story (Kuckartz, 2019). It helps to start the
analysis with a single case, and then it helps to initiate correlating with each other. It has been
seen that this type of analysis is suitable and creates more accurate results. This analysis has
been implemented to develop an excellent qualitative data analysis (Kuckartz, 2019). These are
the main reasons and characteristics of qualitative data analysis and help to consider this
method in this research.

Paradigm (Philosophical Stance)

It must be remembered that this research mainly focuses on the metasynthesis of

existing research studies and is mainly qualitative research. The research is based on naturalist
research philosophy as it prefers qualitative tools of observation and description through
generating essential leads from existing studies (Park et al., 2020). Based on this research
context, the naturalism research philosophy has been explained in the below section.

Research Philosophy

In the context of this research, the naturalism research philosophy has been followed
while conducting this study. The naturalism philosophy has been used to gain knowledge in this
research study by combining evidence from selected research studies (Park et al., 2020).
Through this naturalist research philosophy, the fundamental research was limited to
metasynthesis to interpret published information and filter the information that is important to
this [Link] the data collection and interpretation in an subjective way. Through metasynthesis,
research was able to answer its research question. As naturalistic research focuses on
understanding what has happened in a particular situation and not trying to predict future trends,
 29

this study synthesized existing research around PCOS on women during their reproductive
period to understand the efforts available for managing the psychological and physiological
effects of the PCOS (Park et al., 2020).

This research has determined that naturalism ultimately depends on the qualitative data
analysis tools that lead to conclusions based on reviewing PCOS studies. As this research has
followed the metasynthesis process, qualitative evidence has been interpreted from published
papers on the selected topic. It has been seen that naturalism research philosophy allows the
combination of different research conclusions from different researchers to develop new themes
and explanations for specified research questions through a vivid and accurate description of
complex situations (Alharahsheh & Pius, 2020).

Advantages of Naturalism Research Philosophy

Through the conduction of this research, two advantages of the naturalism research
philosophy have been identified. These two advantages have helped make this research more
informative by providing qualitative evidence from published research papers.

Qualitative Approach

It has been seen that this research philosophy is majorly based on qualitative data due
to the synthesis of qualitative research. As this research has used previous research which has
used qualitative and quantitative data, the qualitative approach allowed for the collection of
diverse evidence about the research question. The qualitative approach gathers rich data, which
helps develop new ideas through understanding the totality of each data used (Alharahsheh &
Pius, 2020).

Flexibility

This research philosophy allows for the utilization of different methods to generate
adequate information which can be used to answer the research question effectively. The
naturalism approach allows this research to synthesize information from various studies around
the research topic (Ryan, 2018).
 30

Disadvantages of Naturalism Research Philosophy

Besides the advantages of the naturalism research philosophy, two disadvantages have
been identified while conducting this research. These two disadvantages are human behavior
and subjectivity (Ryan, 2018).

Human Behavior

This philosophy believes that subjective inferences, as well as conclusions, can be

reached "as long as the person doing the observation" without personal emotion because
human behavior usually comes with emotional responses (Ryan, 2018). Despite this theory,
there is no confirmation that it will occur every time while conducting the research (Ryan, 2018).

Subjectivity

Naturalism research philosophy can be affected by an individual’s judgment or opinions

instead of the outside influence of the research paper (Ryan, 2018). This means that the
researcher may be guided by personal feelings in selecting information leading to biasness.

Ontology
While organizing research, it is essential to find the outcomes of the research as well as
the aims and problems. The research aim should be formulated into an answerable research
question. In the context of this research, this formulation has been essential. The next step is
answering each research question efficiently (Mosca et al., 2018). All of these significant
activities must be done by selecting an accurate methodology. In the context of this research, all
of the activities mentioned above have been done by selecting proper methodologies such as
ontology, epistemology, and axiology. This section has explained the process of ontology used
in this research (Mosca et al., 2018). In a single word, ontology is about the object of inquiry
regarding the established goal to determine and achieve. Through ontology, it was easy to view
the complete research from a specific and alternative standpoint for a better understanding of a
position from the inside (Mosca et al., 2018).

In this research on Polycystic Ovarian Syndrome, the ontology was concerned about the
type and nature of the reality and the social world associated with women (Mosca et al., 2018).
Following this methodology in this study has helped to be concerned with the reality's existence,
nature, and structure as well as possible chances to know about the current world regarding
polycystic ovarian syndrome in women. It has been determined that ontology is directly
 31

associated with the central question. In this context, social entities must be perceived as
subjective and objective. Among subjective and objective ontologies, subjective ontology has
been selected for this research on PCOS (Mosca et al., 2018).

Advantages of the Subjective Ontology

One of the significant reasons for selecting subjective ontology is that the research
background is utilized as a significant part of providing brief information on the selected topic.
The selection of subjective ontology has helped to explain an informative background on the
research topic. In this way, it is understood that background is an initial point of continuous
research (Al-Ababneh, 2020).

Another advantage is that through the selection of subjective ontology, it has been
determined that background research is essential and directly carries the final outcomes and
findings of the research, as happened in this current research on PCOS (Al-Ababneh, 2020).
The reason for not considering the construction is background research is not mandatory for this
type of ontology (Al-Ababneh, 2020).

Before initiating this dissertation, it was essential to get approval from the project
supervisor. The selection of subjective ontology has helped to make the research proposal (Al-
Ababneh, 2020). This method has established clear objectives before embarking on the
research (Al-Ababneh, 2020). This research has defined every possible variable in the
background section and shows the connection between these studies (Al-Ababneh, 2020).

Lastly, when it comes to the application of subjectivism, it helps to avoid conflict of

interest. As this research is specific such as PCOS in women, maintaining reliability and validity
is significant for this project. Subjectivism helps to ensure the research's validity and reliability
(Lukyanenko et al., 2019).

Weakness
One of the significant weaknesses of subjectivism is that it does not consider the
influence of objectivism context (Mosca et al., 2018). Subjectivism can be influenced by
personal influence and opinions on the information used in a research study. Personal opinions
may only be directed to the individual’s interest rather than the research study's interest; hence
biasness can occur. Therefore, it has been determined that subjectivism does not capture the
complete truth of the data (Mosca et al., 2018).
 32

Epistemology
An epistemological perspective under naturalism philosophy is supporting this current
research work. Epistemology aims to uncover practical knowledge. In the research,
epistemological factors are considered internal factors that have been used to analyze gathered
data on relevant research topics. The epistemology principles help the researchers determine
the best approach to support women with polycystic ovaries more practically. The novel concept
of epistemology provides insights that researchers can examine the massive amount of
collected data (McMurtry, 2020). It can distinguish between ethical and biased information
before any knowledge or observation is inserted. Under naturalism research philosophy, the
approach of epistemology adequately observes and measures the reality to describe the
support system for women with PCOS exponentially. As the research involved qualitative data,
integration of epistemological insight seemed fruitful in analyzing and understanding the
psychological condition of participants with positive PCOS (McMurtry, 2020).

Epistemology is concerned with methods of knowledge acquiring, maintaining validity

and scope of the research. It guides the research regarding the constitution of knowledge and
the extent of its transferability. Epistemology influences the adoption of a research framework
that can efficiently discover knowledge. It ensures a legitimate way for data collection. It allows
interpreting those data to establish observations in this study comprised of metasynthesis of the
previous study to develop a new concept on supporting and understanding women with PCOS
(McMurtry, 2020). Another reason behind integrating the epistemological point of view is that it
supports the axiological view regarding value. The philosophical assumption also influences the
research methods that opted the study to adopt an appropriate one. Principles of epistemology
help formulate theories, study design, and research questions from embedded assumptions.
Hence, it enables in-depth investigation of the past support system for women with PCOS. In
this current research work, the epistemological view under naturalism accepted human errors to
some extent (McMurtry, 2020). Nonetheless, it is committed to the subjective measurement of
the filtered research studies and publications. Epistemological approaches strengthen the
relationship between the variables by shaping the interaction mode (McMurtry, 2020).

Advantages of Epistemological paradigm

The nature of the epistemological paradigm emerged as most convenient as the notion
deals with realistic perspectives and is flexible with the changes brought by time or
improvement. Less rigidity of the paradigm allows investigation more pertinently. Content of the
epistemological paradigm encompasses analysis of external and internal factors that can
 33

influence the research work. The epistemological position in naturalist assumptions was
advantageous for this research work (Gamlen & McIntyre, 2018). It is noticeable that the
naturalist position was in place to establish facts and values for the research paper distinctly. It
offers value-free inquiry if needed and procured knowledge based on observations. The
epistemological phenomenon emphasized subjectivity and evidence in terms of only
synthesizing published studies on support systems for PCOS women. Distinctively incorporating
facts and values from these peer reviewed research papers also ensured the research is free
from personal observation or influence. Additionally, the research work's subjectivist
epistemology reflects the position used to shed light on the existing meaningful realities of
support systems and approaches for women with PCOS (Gamlen & McIntyre, 2018). In other
words, it helps to recognize the themes consciously that are inextricably associated with women
with PCOS.

The subjectivist epistemology investigated and experienced the issues with supporting
women with PCOS, along with providing practical instances of existing support systems. It
enables detailed working on the topic and analysis of the sensory perception of PCOS. It
established a relationship between consciousness and real-world practices. It not only
advocates framing knowledge but is also inclined to provide reasoning of selected theories,
published research work, and concepts, along with analyzing its nature and consequences
(Gamlen & McIntyre, 2018). Moreover, the adoption of subjectivist epistemology enables
researchers to establish empirical findings supporting women with PCOS.

Limitations of Epistemology
Though naturalists' epistemological position was prioritized, there are congruent
limitations that were also accepted in current research. The root of naturalists relied on
synthesizing different published research based on previous research, which may contain
information lacking current technological and management advancements. If future advances in
technology and health management techniques are developed and excellently solve the
problem, then the research finding will be insignificant (Pham, 2018).

Axiology
According to Suprapto (2021), Axiology is the branch of methodology that focuses on
investigating the values and their nature considering a philosophical point of view. It is the fourth
defining paradigm of research. This research methodology chooses and maintains a subjective
point of view. It adopts subjectivism in interpreting information gained from the synthesized
studies, thereby conforming to the naturalist values incorporated in the philosophical stances
 34

aimed to be applied for the sake of the research (Park et al., 2020). Choosing an axiological
point of view has ensured that the qualitative approach chosen for synthesizing information was
thoroughly structured and free of value. The reliance on naturalism is quite extensive on
subjectivism. Therefore, there is a complete dismissal of the objective experiences and values
of the researcher as the Objectivist viewpoints are instead deemed unnecessary when relating
to naturalism. It also allows a researcher to personally get involved in the research information
synthesis (Park et al., 2020).

During the research, all the paradigms were considered, and the rules and regulations
about the paradigms and guidelines that are necessary to follow and implement their viewpoints
were thoroughly maintained. Thus it can be said with utmost confidence that apart from the
epistemological paradigm, the details and the necessity are necessary to maintain an
ontological viewpoint. The axiological standpoint was considered and implemented when
dictating this particular research's philosophical necessities. Al ethical issues were considered
when planning for this research (Aliyu et al., 2018).

Axiology and its advantages

A good research study is permitted by axiology. The research that has been conducted
was to justify the objectives that were considered in the first place. There has been an absolute
demonstration of unbiasedness, diligence, detailed attention, and scientific curiosity by the
researcher since the beginning of this study to help understand the adversity of PCOS and how
women get severely affected due to the disease. The implementation of science in this study
can be termed worthwhile as it was strictly problem-centered, considered, and evaluated the
literature. At the same time, it reviewed the severe crevices surrounding the research conducted
(Aliyu et al., 2018). There was an immense amount of commitment implemented before and
while this study even began in the first place. The influence of axiology is implemented so it can
be classified as diverse (Aliyu et al., 2018).

To incorporate a structure in this study to the necessary metasynthesis related to the

previous research study viewpoints, axiology was used to provide a better understanding. The
sources used are ethical and peer-reviewed to make this study evaluated and understood in the
right direction (Aliyu et al., 2018). There has been an adequate explanation for the
complications that PCOS does to women, and sufficient resolutions provided for the problems
that the disease produces. There has been an immense amount of questioning about the impact
that the disease causes, whether the treatments will be significantly better in the future and
whether this would bring fruitful changes to society. These viewpoints were considered for this
 35

particular research. The systemic viewpoints have not been neglected as well. The theories that
have been presented represent the existing opinions, decisions, and methodological
approaches that are with naturalism as well as cultural philosophy (Aliyu et al., 2018). Different
spheres possibly associated with the axiology and its methodological pluralism are considered
to categorize the value. The ethical aspects and issues connected with this study were
thoroughly analyzed while planning the research proposal (Aliyu et al., 2018). Concepts of
behavior that could be classified as truthful and wrong were studied before using any sources
and ascertaining approaches. Attribution of value to the several aspects of the research, the
data, and the readers are also considered. The issues and traits that depend on morality were
thoroughly analyzed and were ensured to be incorporated (Aliyu et al., 2018). It was ascertained
that this dissertation is an imposition and harm, hurts sentiments, and is a burden to legality and
society. The conduction of the research has been peaceful and respectful without crossing
teleological boundaries. The actions that were undertaken have been ascertained to be
beneficial to society. The interpretation of the data is truthful and fair. The code of conduct for
exploiting the accessibility of avid sources and data utilization with accuracy has been ensured
(Aliyu et al., 2018). There has been no inclusion of biases or prejudices that could seem to
belong to the researcher, which could affect the purity of the study. Personal viewpoints have
been entirely avoided while writing the axiological paradigms. Personal viewpoints could affect
the technicalities and methodologies of research, thereby ultimately affecting society.

There has been a presentation of facts by utilisation of secondary sources. The scientific
facts and the ethical values were divided, categorized, and treated separately, thereby not
compromising the foundation of the epistemology (Aliyu et al., 2018). There has been a
combination of methodology, epistemology, and ontology, including axiology. The ontology has
been constructed with truth and proper findings using methods of quality as the philosophy of
naturalism demands.

Qualitative methods and their exploitation have often been the best way to present
reality. The analyzed and presented contents can be immensely useful for future practical
applications. These methods can be hugely gaining insights, thereby proving to be a source of
inspiration for other researchers.

Axiology and its limitations

The research presented certain limitations as well. It questioned the nature of the
research studies and the co-relations between the questioning of the nature of the research
studies used (Kotlyarova et al., 2015). Distinct setting boundaries by compartmentalizing them
 36

has proven to be complicated. Notions concerning the paradigm can be confusing when
concerned with the epistemological stances (Aliyu et al., 2018). There was difficulty in finding
necessary points that encompassed all the ethical guidelines. Not being able to state the ethical
factors can prove to be a source of hindrance and hence a factor of demotivation, incoherence,
confusion, and loss of determination. Assessment of the study to find co-relation of science,
social relations, and culture was also a barrier. The lack of unity in understanding the value and
its essence is another limitation. Apart from the logical analysis, there needs to be an
examination of the values' role and their effects related on society and its dynamics.
 37

CHAPTER 4

Results
The research strategy utilized in this study yielded 6,617 articles from three databases.
After the articles were screened, 1562 duplicate articles were removed, while 5,004 researchers
were excluded because they failed to meet the selection requirements according to their
abstract and titles. The remaining 51 articles were further screened through full-text review, and
28 studies were excluded due to their lack of essential data (information about components of
MetS, impacts of PCOS on women, etc.) about the research topic. Seven articles were
excluded because they included data on participants out of the range between 10 and 16 years,
and four other studies were excluded because they were not written in English. A total of 12
articles were included in the review and metasynthesis. The selection process of research
articles to be included in this research followed the PRISMA guidelines. The current research
presented its data based on Random Cross-sectional prospective, case-control, cohort, and
different observational researches using various diagnostic criteria. The figure below shows the
flow chart of the selection process and literature search:

Figure 2: Flow chart for the selection process and literature search
 38

Characteristics of the participants

Hadjiconstantinou et al. (2017) researched a specific range of symptoms linked to
women with PCOS. Their study analyzed a sample of 12 women (n=12) aged from 17 to 51
years. The sample comprised one black African, four south Asians, and seven white British
(Hadjiconstantinou et al., 2017).In the study, the participants in the sample noted varying
symptoms related to PCOS. Most participants (n=11) noted that Hirsutism was the main
symptom, and one lady symptom of Menstruation and infertility problems (n=1). Weight
difficulties (n=10) were used to analyze ten participants' symptoms.

Characteristics of the Participants Total

Symptoms*
Hirsutism 11
Heavy or Irregular Periods 11
Difficult Maintaining Weight / Weight Gain 10
Acne 3
Mood Swings 1
Infertility 4
Tiredness 1
Skin Discoloration 1

Distribution within Age Range

17-27 3
28-37 2
38-47 4
48-57 1
Ethnicity (Self-Identification)
South Asian 4
Black African 1
White British 7
Time/Age of Diagnosis
Early - Mid Teens 3
Early - Mid 20s 5
Early – Mid 30s 1
Early – Mid 40s 3
 39

Figure 3: Characteristics of the Participants (Source: Hadjiconstantinou et al., 2017)

According to Hadjiconstantinou et al. (2017) research, emotional support was essential

to PCOS patients. The participants differed on “how much support” they had received from their
families, with some noting that they had not received any family help. The participants
acknowledged that they significantly appreciated sufficient help from healthcare providers since
they could listen to and understand their PCOS. Hadjiconstantinou et al. (2017) identified that
women supported the idea of “education sessions” for women with polycystic ovary syndrome
immediately after diagnosis. The education programs could support women with PCOS by
improving their understanding and knowledge and creating specific opportunities for them to
share their experiences.

Psychological Health Impacts of PCOS on Women

Research by Adebis et al. (2021) analyzed the essential coping strategies and their
effectiveness. In their research, one participant acknowledged pharmacological therapy such as
metformin, spironolactone, and contraceptive pill as medications that have been helping them
improve their skin quality by blocking the male hormone (Adebis et al., 2021). On the other
hand, Zahiri et al., 2016 suggested a significant need for an education program on PCOS
among women and their respective medical conditions. From these studies, it is clear that, apart
from the medical situation, PCOS also causes psychological impacts on their health.

The selected studies' psychological health effects of PCOS on women were established
through synthesizing the selected studies. The estimated prevalence of the psychological
effects using a 95% confidence interval was categorized into three; Elevated existing
depression, Major depressive disorder, and common mental health among women with PCOS.

Major Depressive Disorder

Depression is a mood disorder that causes a continued emotional and mental state of
sadness and loss of interest in the majority of daily life activities. Depression affects how an
individual feels, thinks, and behaves, leading to diverse physical and emotional complications
(Kerchner et al., 2019). In general, major depressive disorder affected 17% of women with
PCOS, ranging between 0% and 67% (Delanerolle et al., 2022). All the selected research
articles estimated a prevalence of ≥ 10%. However, a Swedish study and two Middle Easter
Studies indicated a higher prevalence of 67%, 29%, and 22%, respectively (Delanerolle et al.,
2022). Most studies showed substantial heterogeneity with I2 of 93.98%, but the USA had a
higher heterogeneity with I2 of 71.33% (Delanerolle et al., 2022). Two studies from the Middle
 40

East were homogeneous. The figure below shows the prevalence of major depressive disorder
by region:

Figure 4: Major Depression by Region

Elevated Existing Disorder

Depression in women with PCOS was synthesized across all selected studies, which
included 3097 women. The average estimated average of depression was 33% (Delanerolle et
al., 2022). The prevalence of depression was estimated across the region, and it was found that
most of the regions had similar averages except for India, which had a higher prevalence of
64%. Also, the synthesizing of the studies indicated substantial heterogeneity across and within
regions, and the general heterogeneity was estimated to be 93.24% (Delanerolle et al., 2022).
The figure below shows the prevalence of existing depressive disorders by region:
 41

Figure 5: Elevated Existing Depression by Region

Anxiety among Women with PCOS

Anxiety is a mental health condition that causes nervousness, fear, and panic. Women
with PCOS can have anxiety disorder due to the medical issues of the syndrome (Kerchner et
al., 2019). The prevalence of anxiety across the regions studied showed that the USA had the
highest prevalence, where 22% prevalence was for non-whites, and the prevalence among
whites was 78% (Delanerolle et al., 2022). The European region was the second with a
prevalence of 74%, where 80% prevalence was for whites and 18% for non-whites. Australia
and the Middle East had a prevalence of 38% and 42%, respectively (Delanerolle et al., 2022).
The average age for most people experiencing anxiety was three years (Delanerolle et al.,
2022). The figure below shows the prevalence of anxiety disorder by region:
 42

Figure 6: Anxiety Prevalence by Region

Common Mental Health

The common mental health issues that can occur in women with PCOS may include
personality disorders, eating disorders, mood disorders, post-traumatic stress disorder (PTSD),
etc. These mental states cause disturbances in an individual’s emotional regulation, cognition,
or behavior (Kerchner et al., 2019). As stated by Hadjiconstantinou et al. (2017), most women
with PCOS do not receive the necessary support from family and relatives, which can
significantly increase the prevalence of women with PCOS to mental health disorders. The
prevalence of the common mental health of women with PCOS was an average of 31% across
all the regions (Delanerolle et al., 2022). The prevalence indicates that women with PCOS are
susceptible to common mental health complications. The figure below shows the prevalence of
common mental health disorders by region:
 43

Figure 7: Common Mental Health Disorders

Research by Adebisi et al. (2021) analyzed the essential coping strategies and their
effectiveness. In their research, one participant acknowledged pharmacological therapy such as
metformin, spironolactone, and contraceptive pill as medications that have been helping them
improve their skin quality by blocking the male hormone (Adebis et al., 2021). On the other
hand, Zahiri et al. (2016) suggested a significant need for an education program on PCOS
across women and their respective medical conditions. Another research by Zahiri et al. (2016)
suggested a significant demand for the education program on PCOS at a broad level among
women and their medical situation. Their research recommended creating awareness and
knowledge in families, communities, and healthcare providers. Without the effectiveness of the
education programs, medical therapy for women with PCOS is essential. The research
established that pharmacological procedures used in women with PCOS are unreliable because
neither the European Medicines Agency nor Food or drug administration has ever permitted a
specific drug to medicate PCOS (Adebis et al., 2021). Therefore, educational programs should
enlighten people on healthy lifestyles and ways of dealing with the physiological and
psychological effects associated with PCOS to reduce its severity in the community.
 44

CHAPTER 5

Discussion
It has been established that combined symptoms of PCOS include Hirsutism, weight
gain, and severe effects that cause infertility among women in the reproductive period. The
manifestation of PCOS in women causes physiological and psychological distress (Adebis et al.,
2021). This research has explored how the harshness of PCOS symptoms impacts women’s
lifestyles both from societal and physiological perspectives. The research has indicated that
increased psychological distress was caused by women’s poor lifestyle and lack of support from
families and society. PCOS symptoms involve exposure to Hirsutism, demonstrating low self-
esteem and body image (Adebis et al., 2021). The combined effects create practical impacts in
terms of social and personal interaction. It has been established from selected research studies
that there is a growing necessity to provide education programs and information about PCOS,
its diagnosis, and associated psychological impacts for women to understand their conditions
and strategies to handle them (Zahiri et al. 2016). The research for this study established that
providing education programs can effectively improve the well-being of women with PCOS. After
reviewing the relevant literature for this research, it has been established that psychological
support for women with PCOS is critical since most women with PCOS are undergoing
emotional distress.

The meta-synthesis included 12 published studies which mainly revealed a 20%

prevalence of common psychological disorders symptoms such as depression and anxiety.
However, there was a lot of variation among all the research studies. Body mass index (BMI),
geography, age range, study design (including the utilized psychiatric examinations), sample
size and research approach, population ethnicity, and other factors can all be sources of this
variation (Brutocao et al., 2018). The synthesis research highlighted a number of essential
themes, including psychotic disorders, PTSD, eating disorders, and bipolar disorder, as well as
signs of anxiety and depression.

Despite being the most prevalent reproductive endocrine health issue that affects
women throughout their whole reproductive lives, PCOS is frequently linked to a serious
unfavorable patient experience, including a delayed diagnosis that may have contributed to the
symptoms worsening (Brutocao et al., 2018). Due to the chronic disease, difficulties with
consistent medication adherence are a typical problem; nevertheless, lifestyle adjustments may
help reduce the disease's long-term effects. However, after receiving a diagnosis and speaking
with their doctors, only 19% of women claimed to be aware of all issues linked to PCOS
 45

(Brutocao et al., 2018). The usual PCOS symptoms, such as hirsutism, irregular menstrual
cycles, acne, obesity, male-pattern baldness, and infertility, may have an additional detrimental
effect on a patient's self-esteem, which may result in psychological stress (Brutocao et al.,
2018). Synthesis accounts, however, suggest that clinicians place a great deal of emphasis on a
select few symptoms, such as infertility, rather than taking a comprehensive approach to all
significant aspects of the condition, such as the long-term mental and physical health
consequences and the impact of treatment and diagnosis on the woman's quality of life
(Brutocao et al., 2018). Additionally, a higher prevalence of psychiatric illnesses is linked to
PCOS.

According to this meta-synthesis research, 31% of women with PCOS had common
mental health diagnoses and symptoms. Similar findings were made by Hillman et al. (2020),
who discovered that a staggering 74.9% of women in their study who were diagnosed with
PCOS said the disorder had a negative impact on their mental health (Hillman et al., 2020).
However, despite the report's results that the related mental health symptoms had a significant
detrimental impact on psychological wellness, as many as 34.9% of the women opted not to
address them with their medical practitioner (Hillman et al. 2020). The patient's ethnic
background might play a significant role in this. In contrast to Asian women with PCOS in the
United Kingdom, Hillman et al. (2020) found that Caucasian women with PCOS had higher
chances of discussing their mental health with their doctors (Hillman et al. 2020). Clinicians and
other healthcare professionals should examine the needs of minority ethnicities more
thoroughly. This would enable the provision of individualized care that is sensitive to cultural
differences, thereby enhancing both clinical and patient outcomes.

In England, approximately 1 in 6 persons match the diagnosing requirements for

common mental health disorders (Tay et al., 2019). Compared to their White British
counterparts, Black, Asian, and Minority Ethnic (BAME) groups are far more susceptible to
being affected by the Mental Health Act, which can be explained by increased rates of observed
mental disorders and lower levels of health assistance (Mayer et al., 2015). Studies have looked
at attitudes around mental illness in minority ethnic communities as well as impediments to care.
Poor reporting rates for mental illness are due to several factors, including PCOS, related
stigma, limited English proficiency, unpleasant interactions with healthcare providers, and
awareness of accessible treatments (Mayer et al., 2015). These problems may significantly
negatively influence individuals with PCOS's mental health, and patients' reluctance to seek
treatment may worsen existing psychiatric diseases or prevent them from being diagnosed with
 46

new mental health symptoms. Therefore, it is crucial to analyze the risk of mental disorder in
PCOS-affected women thoroughly. The Royal College of Obstetricians and Gynecologists
(RCOG) concurs and advises routinely checking all PCOS-affected women for psychosocial
concerns (Mayer et al., 2015). However, our meta-synthesis shows that there is research, both
in the UK and internationally, looking at psychiatric comorbidities in PCOS patients. This was
mostly caused by the fact that patient ethnicity and race were not addressed in PCOS research
studies on patient mental health.

In this meta-synthesis review, anxiety and depression were the two major mental
illnesses PCOS patients most frequently reported having. Indeed, the significant risk of both
new and current diagnoses of depression in women with PCOS is mentioned in a number of
recent studies. This meta-synthesis supported these findings, which revealed that 17% of PCOS
patients had significant depression and 33% had heightened pre-existing depression, with a
very high degree of variability in both subthemes between and within regions (Mayer et al.,
2015). Contradictory research has been done in the past to determine the true prevalence of
depressive disorders among minority ethnic group patients with PCOS (Mayer et al., 2015). Due
to disparities in research study methodologies and diagnostic procedures, as well as the
underrepresentation of minority ethnic group patients in studies, this meta-synthesis was unable
to pool statistics by ethnicity or race. Therefore, it was unable to determine the actual
prevalence of heightened preexisting depression and recently diagnosed major depression
among minority group women with PCOS. But according to this synthesis, some ethnic groups
or races have higher depression rates than Caucasian Patients with PCOS.

Panic disorder, generalized anxiety disorder, social anxiety disorder, separation anxiety
disorder , and specific phobias are among the anxiety disorders that can make it challenging to
go about daily activities (Liu et al., 2021). Women are twice as likely as males to experience
anxiety problems, and generalized anxiety symptoms are far more common in PCOS-positive
women than in PCOS-negative women (Liu et al., 2021). This study found that few published
studies discussing the prevalence of anxiety in PCOS women. The prevalence of generalized
anxiety disorder was 41% among women with PCOS in this study. However heterogeneity was
significant at 94.83% (Liu et al., 2021). This heterogeneity, which included results from several
geographies, implies that there is no variation in the prevalence of anxiety among PCOS-
positive women based on geography (Liu et al., 2021). Due to a lack of reliable data, the
research could not determine the prevalence of anxiety among various ethnic groups and races
in women with PCOS, similar to how depression subtheme analysis was unsuccessful.
 47

Worldwide, there is a significant prevalence of eating disorders (EDs), especially among

younger women (Liu et al., 2021). It has been discovered that factors that may alter body image
have been linked to the development of EDs. Body image alterations and self-esteem issues
are fundamental to the emergence of common EDs (Liu et al., 2021). When it comes to
disrupted body image perception linked to EDs, traits including
hyperandrogenism, acne, hirsutism, weight gain, and androgenic alopecia frequently play a role.
Although helpful in understanding the connection between EDs and PCOS, existing literature
finds it difficult to present information on racial variations in PCOS and EDs (Liu et al., 2021).
One study found that Hispanic, Black, and Mixed Race women with PCOS had higher EDE-Q
scores (a self-rating questionnaire of the scope and magnitude of ED characteristics) in
comparison to Caucasian women. At the same time, the other reported EDs to be comparable
in the minority population (Roessler et al., 2012). Only two observational researches were found
that addressed EDs in minority community PCOS patients. Although they document an elevated
risk of disordered eating habits in PCOS women in comparison to the control populations, they
agree. However, inconsistent scientific methods and the utilization of external cohorts from a
different nations render the evidence insufficient to reach definitive conclusions on the particular
prevalence of EDs in minority women with PCOS, highlighting the need for extensive studies to
comprehend the disparities in PCOS and affiliated EDs among ethnic groups.

In a large-scale investigation conducted in Sweden, people with PCOS were found to

have a significantly higher prevalence of psychotic diseases, including schizophrenia (Roessler
et al., 2012). Studies examining the relationships between circumstances are scarce,
nevertheless. Only one cohort study examined the prevalence of psychotic disorders in
Taiwanese PCOS patients and found no statistically significant difference in the prevalence of
schizophrenia between the two populations, even though people from minority ethnic
backgrounds had been identified to experience a higher rate of psychosis compared to the
Caucasian population in the UK (Roessler et al., 2012). This emphasizes the necessity for more
high-quality research to evaluate PCOS-related psychotic disorders among various ethnic
groups.

It has been noted that bipolar disorder (BD) is more common in women with PCOS than
in the general population, and given that it carries a 12-fold greater risk of suicide, it is crucial to
look into possible causative relationships between the two disorders (Roessler et al., 2012).
There is a limitation, too, in that women getting therapy for BD are found to have a high
prevalence of menstruation problems (Roessler et al., 2012). Therefore, it is crucial to consider
 48

confounding factors including medication and pre-existing diseases in research examining the
prevalence of mental health consequences, like BD, in women from minority ethnic groups who
have PCOS. A countrywide cohort study from Taiwan found no appreciable difference in the
prevalence of BD in PCOS women in comparison with the control population. In contrast, a
study from the Kashmir Valley observed BD rates of 2.72% opposed to 0.00% in control
participants (Roessler et al., 2012). The prevalence in various communities must therefore be
understood through further study because associations cannot be made based on current scant
information.

This meta-synthesis review has further demonstrated the diversity of psychiatric disease
diagnoses. The review found that clinicians used 8 different self-report questionnaires in their
approaches (Tay et al., 2019). This restricts the generalizability of our investigation and any
estimation of the prevalence of a particular psychiatric condition.

Generally, although the majority of studies utilized Rotterdam Criteria in the PCOS
diagnosis, the research employed the National Institutes of Health Criteria, 1990 to diagnose
PCOS, which will introduce diagnostic bias (Tay et al., 2019). To eliminate the sample bias,
future research should work to apply globally acknowledged, consistent criteria for mental health
and PCOS condition diagnosis.

Medical professionals might not be aware of cultural differences' influence on how

patients report their physical and mental health issues. Minority community members are
generally less likely to use mental health services or ask for assistance before symptoms
seriously impair their ability to perform (Simkhada et al., 2021). Members of the Nepali and
Iranian populations report better support and care for mental illness from healthcare
professionals who have received culturally-sensitive training, according to Simkhada et al.
(2021). Furthermore, the study's physicians noted that offering services sensitive to cultural
differences require a greater awareness of other cultures (Simkhada et al., 2021). To better
comprehend minority communities' knowledge and attitudes about mental illnesses and to
enable clinicians to deliver a comprehensive, successful treatment approach while working with
various populations, it is crucial for healthcare practitioners to get cultural norms training
(Simkhada et al., 2021). Training in cultural competency may help boost patients' confidence in
medical professionals and encourage early dialogues about how PCOS may hurt patients'
psychosocial well-being in minority cultures (Simkhada et al., 2021). As a result, this will help to
personalize patient clinical care, discover mental sequelae of PCOS early, and treat them
effectively and permanently.
 49

Regarding the provision of education and support, Tabassum et al. (2021) argued that
group education to women and adolescents on PCOS and its symptoms would efficiently
confine differences between women with PCOS. The authors also insisted on educating the
healthcare providers to help them effectively identify PCOS at early stages and handle culturally
diversified patients. Community-level education on PCOS can be fabricated and cultivated to
increase awareness and understanding of the PCOS disease hence increasing women’s ability
to monitor possible PCOS and reporting to elevate timely diagnosis (Tabassum et al., 2021).

Infertility impact associated with PCOS is a major cause of emotional distress affecting
the quality of life of women with PCOS. The research established that PCOS patients with
obesity have higher chances of developing difficulties when conceiving. In some societal
landscapes,, when women lose their pregnancies or become infertile due to health
complications, societal stereotypes and discrepancies lead to their discrimination (Tabassum et
al., 2021). Also, PCOS patients undergo changes in their physical appearance due to irregular
hormonal secretion and loss of femininity. These PCOS impacts cause PCOS women to have
low self-esteem, anxiety, and frustration due to the feeling of being discriminated against and
losing their feminine body shape (Tabassum et al., 2021). The high depressive state caused by
the PCOS impacts affects the patient's quality of life, attracting cardiovascular complications,
metabolic syndrome, perinatal mental disorder, etc. The research has established that loss of
appetite, daily fatigue, and sleeping disorder is the most common side effects of the depressive
state of PCOS patients.

In relation to educating or supporting PCOS patients or communities or their families,

this research paper explored detailed concepts to satisfactorily understand information in the
study. The research paper mentions the provision of education and support to PCOS women to
elevate their quality of life. Since no specific treatment procedure exists for PCOS, developing
activities and programs that promote quality of life for the patients is critical (Tabassum et al.,
2021). The programs include education, community, and family support where the patients can
be accepted and encouraged to recover from the syndrome. Hirsutism has been determined to
be the primary cause of psychological distress among PCOS patients. PCOS patients
experiencing Hirsutism indicated that they always feel unfeminine and socially uncomfortable
(Tabassum et al., 2021). However, it was noted that the level of Hirsutism varies with ethnicity.
Researchers have established that the Hirsutism consequence of psychosexuality, causes
higher levels of distress among women with PCOS. This study has established that the higher
psychological distress and anxiety due to Hirsutism significantly reduces the patient's quality of
 50

life. The Hirsute women mostly develop “social phobia,” where they are afraid of mixing with
other people because the situation develops anxiety and low self-esteem.

Additionally, an individual's cultural variables and environments impact the PCOS

symptoms. This research established that women who a White are more concerned with their
health, and have higher chances of seeking medical intervention for PCSO at early stages than
women from the BAME group.
 51

CHAPTER 6

CONCLUSION AND LIMITATIONS

Conclusion
PCOS is a dependent disease that is majorly related to the quality of life. It has been
established that support and education programs can help women with PCOS increase their
quality of life by gaining knowledge and understanding about PCOS. Developing suitable
support systems and programs, such as learning about early symptoms of PCOS disease, can
improve early diagnostics. Also, programs like healthy diets, mental health management
techniques, supervised physical activities and therapeutic intervention also promote the
improvement of the quality of life of PCOS patients. Most of the women reported that after being
diagnosed, they felt relaxed since they could get professional help from healthcare
professionals. Some studies have recommended the control of blood circulating lipids which can
be achieved through supervised intermittent exercising. Moderate to excessive physical
activities can reduce the level of lipids in the blood system and affection condition of the ovaries.
Another cause of increased PCOS in women is high insulin resistance, elevating blood glucose
circulation. Research has recommended that routing jogging, exercises, and yoga are essential
lifestyles that improve quality of life and reduce the chances of PCOS. Among the diverse
PCOS causes established by researchers, it is evident that lifestyle disorders require strategic
mitigation plans with proper habits in lifestyle. Increased blood pressure increases the risk of
accumulation of fats in the ovaries leading to ovaries depositing lipids in the form of cysts. The
cysts accumulation increases the risk of imbalancedd hormonal levels, leading to irregularity in
menstrual cycles. It is critical to note that PCOS is a psychological and psycho-hormonal
disorder requiring counseling and medication.

This study indicates how few ethnic minorities are represented in studies among PCOS
patients looking into potential mental illness sequelae. Extensive research studies should be
developed and carried out as part of an international initiative to ascertain whether there is a bi-
directional association between PCOS and mental health disorders among ethnic minorities.
The migration patterns that alter the regional and global population are crucial in the shifting
requirements for women's physical and psychological health. To maximize the total clinical care
provided to these patients, it is crucial to regularly and carefully examine the most recent
research. The accompanying complexities have an impact on clinical practice as well as access
to the healthcare system. Therefore, healthcare practitioners working in primary and secondary
care settings should access cultural appropriation-based training.
 52

Limitations
A number of limitations impacted these meta-synthesis conclusions. While the
studies frequently found that PCOS women experienced considerable emotional discomfort,
part of this was self-reported and subjective, lacking a formal diagnosis. This could conceal the
actual frequency of common Mental illnesses, like anxiety and depression, among PCOS-
affected women. The considerable heterogeneity seen across all subtheme meta-synthesis is
another drawback. A variety of sources of heterogeneity caused the differences between
estimates. These include the variety of scales employed and the threshold selection, both of
which, despite the fact that many are equivalent, cause variances. Other variables contributing
to the results' variations include changes in age range, geography, body mass index
(BMI), study design, methodology, sample size, population ethnicity and other characteristics,
and the proven unobserved heterogeneity.

Different groups may be affected differently by the cultural variations in how Mental
health symptoms are reported across locations, which may be made worse by the complicated
interactions between stigma and acceptable norms within minority communities. Another
limitation of all the research included in this evaluation is the disparity between reporting mental
health symptoms and diagnoses. S self-reported use of psychiatric medication and clinical
diagnosis were among the many unique assessment methodologies employed to evaluate the
risk of major psychiatric illnesses, injecting heterogeneity into the research included in this
analysis. As a result of questionnaires' propensity to screen rather than diagnose, this may
restrict the generalizability of the data acquired and conceal the true prevalence of a particular
psychiatric condition.
 53

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Appendices

Appendix A
List of Included Journals
S/N Title and Author Study Design Result Conclusion
 60

1 “The effect of Polycystic Prospective Women of Conclusion:

ovarian syndrome on the study reproductive PCOS is
mental health of women of age are interrelated with
reproductive age” estimated as the psychological
(Adebisi et al., 2021) most affected by health and should
PCOS, with be assessed at an
severe early stage to
complications balance
and mental psychological
disturbances health
2 “The prevalence of Meta-analysis Using different Conclusion: The
polycystic ovary syndrome: a Experimental diagnostic study collectively
brief systematic review.” research criteria, the interprets the
(Deswal et al., 2020) study burden of PCOS
determined the and supports an
pooled early diagnosis to
prevalence as the upwards
21.27% prevalence.
3 “Metabolic Syndrome in Prospective They estimated Conclusion:
patients with polycystic cross-sectional the prevalence Women with
ovary syndrome in Iran” study, of metabolic PCOS possess a
(Zahiri et al., 2016) Experimental syndrome in high risk for the
Design women with development of
PCOS is 28.8%. metabolic
It stated that the syndrome and its
levels of HDL interlinked
and LH are complications
comparatively
lower in patients
with PCOS
4 “Perinatal mental health in Cross-sectional They observed Conclusion:
women with polycystic ovary Experimental that PCOS is Women with
syndrome: a cross-sectional study related to the PCOS have a
analysis of an Australian development of higher prevalence
 61

population-based cohort” perinatal and of perinatal mental

(Tay et al., 2019) antenatal disorders which
depressive should be
symptoms and screened.
anxiety
5 “Impact of polycystic ovary Cross-sectional, The results Conclusion:
syndrome on quality of life of prospective and indicated Sociodemographic
women in correlation to age, observational healthy control factors influence
education and marriage” study of women with PCOS and healthy
(Tabassum et al., 2021) PCOS depends control among
upon women along with
socioeconomic their quality of life
status; it shows
that 97% of
PCOS cases
occur below the
age group of 30,
in 78% are in
control
6 “Supportive relationships, Experimental It analyses the Conclusion: Group
psychological effects of study design emotional and cohesion and
group counseling in women relational counseling are
with polycystic ovary aspects of expressed as a
syndrome” PCOS patients medium of
(Roessler et al., 2012) emphasizing emotional support
their health to patients with
behavior PCOS and benefit
their health and
wellbeing.
7 “Understanding and Exploratory A wide range of Conclusion:
supporting women with research design symptoms, Improved daily
polycystic ovary syndrome: a including living of women
qualitative study in an Hirsutism, and with PCOS and
ethnically diverse UK weight gain, are related
 62

sample” analyzed, which implications and

(Hadjiconstantinou et al., leads to provided
2017) psychological educational
distress among support to cope
the PCOS with it.
patients
8 “How close are we to Systematic Analysis Conclusion:
diagnosing polycystic ovary review and showed that miRNA
syndrome with miRNAs: A meta-analysis miRNA significantly takes
meta-analysis and review.” improved the part in reducing
(Liu et al., 2021) accuracy of the diagnosis time
PCOS diagnosis of PCOS
9 “A Systematic Review and Systematic The study Conclusion:
Meta-analysis of Polycystic review and analyzed the PCOS is
Ovary Syndrome and Mental meta-analysis prevalence associated with an
Health among Black Asian among different increased risk of
Minority Ethnic populations” ethnicities has mental health
(Delanerolle et al., 2022) not been disorders,
thoroughly including
evaluated. depressive s,
anxiety, and other
mental health
disorders.
10 “Emotional distress is a Systematic To examine Conclusion:
common risk in women with review and emotional Women with
polycystic ovary syndrome: a meta-analysis distress and its PCOS exhibit
systematic review and meta- associated significantly more
analysis of 28 studies.” features in emotional distress
(Veltman-Verhulst et al., women with than those without
2012) PCOS. PCOS.
11 “Psychiatric disorders in Systematic To examine the Conclusion:
women with polycystic ovary review and prevalence of PCOS is
syndrome: a systematic meta-analysis any psychiatric associated with an
review and meta-analysis” disorder in increased risk of a
 63

(Brutocao et al., 2018) women with diagnosis of

PCOS. depression,
anxiety, bipolar
disorder, and
obsessive-
compulsive
disorder.
12 “Polycystic Ovary Syndrome Exploratory To study the Conclusion:
and Insulin: Our research design contribution of PCOS carries an
Understanding in the Past, insulin inherent risk of
Present and Future” resistance to insulin resistance
(Mayer, Evans, & Nestler, anovulation in and, hence,
2015) PCOS and the metabolic
high risk for consequences for
Type 2 diabetes, which women with
metabolic PCOS should be
syndrome and screened
early regardless of BMI
cardiovascular or degree of
disease. obesity