The mental health implications of PCOS are not often discussed even though this condition increases risk for anxiety and depression by 3x.
Norepinephrine, dopamine, and serotonin are well known in the psychiatric field to be pertinent biochemical regulators of our mood and psychological well-being (1, 2, 3). These three neurohormones form the foundation of current biochemical mental health pharmaceutical treatments in conjunction with psychotherapy and lifestyle modifications.
Although this triad is not exclusively the only group of hormones that can lead to mental illnesses; it is important to also consider the following hormones when working with your healthcare provider.
Estrogen (E1, E2 and E3) is a group of hormones that play a major role in our body’s physiology, ranging from bone health, female characteristic developments, to our emotional well-being.
Focusing on mental health, estrogen regulates neurotransmitters such as serotonin, dopamine, epinephrine, and norepinephrine, which are involved in mood regulation. Estrogen increases both production of serotonin (the “feel good” or “happy” chemical), as well as serotonin receptors in the brain. Estrogen is involved in regulation of endorphins, a group of hormones that stimulate physiological pathways associated with blocking pain and bringing a rush of euphoria and happiness. Fluctuating levels of estrogen is associated with mood swings and irritability.
Low levels of estrogen is linked to lower levels of serotonin, which can cause mood swings, depression, trouble concentrating, fatigue, and irritability. Overly high levels of estrogen along with low levels of progesterone, known as estrogen dominance, is associated with depression, irritability, fatigue, memory problems, mental fog, and anxiety as well.
Apart from the reproductive shifts associated with progesterone, high levels of the hormone is associated with increased amygdala sensitivity (the part of the brain associated with the fight or flight panic response) leading to a greater likelihood of anxiety, depression, insomnia, and a general glum (4). Low levels of progesterone can contribute to estrogen dominance and mood changes such as anxiety, depression, mental fog, irritability, and more.
Dehydroepiandrosterone (DHEA) and it’s sulfated form DHEA-S is the most highly concentrated hormone naturally occurring in our body. As a precursor to other hormones such as testosterone and estrogen, DHEA is essential for healthy functioning.
Low levels of DHEA and DHEA-S is associated with depression; some studies have even found positive results when treating older depressed patients with DHEA supplements (5, 6). Although DHEA supplementation tends to quickly raise natural testosterone levels, and therefore comes with a long list of side effects including hirsutism, insulin resistance, insomnia, and abnormal menses.
Further research is needed to understand the physiological effects of DHEA; efficacy of DHEA supplementation is low and the risk of drug interactions or strong side-effects are high.
Although our thyroid is usually associated with metabolic disorders, the metabolism affects energy rates for our entire body. Activated by thyroid stimulating hormone (TSH) the thyroid gland releases hormones T3 and T4, which differ in the number of iodine molecules present.
T3 and T4 are mood regulators that influence the metabolic rate, and therefore can be directly associated with our energy levels and emotions.
Known widely as the “stress hormone”, cortisol is an essential hormone involved in our fight-or-flight response.
Due to the fast pace of modern society, oftentimes our bodies can perceive unending chronic stress; our adrenal glands can continuously release cortisol which stimulates chronic inflammation throughout the body. Besides resulting in increases in blood sugar, blood pressure, and fat storage, raised cortisol and inflammation levels are correlated with higher rates of depression, anxiety, and other mental health conditions. Serotonin is reportedly dysregulated with a consistently high level of cortisol, chronic stress and bodily inflammation (7).
The source of excessive cortisol can be an adrenal tumor, genetic disorder, or more commonly chronic stress from work, exercise, relationships, and life in general. Lifestyle modifications, such as mindfulness and meditation, can help to reduce stress and cortisol levels.
Hormonal changes often lead to fluctuations in body weight, hair thinning or excessive growth, facial acne, and other physical transformations which can contribute to our self perception, body image, and self-esteem. It is important to recognize how physical changes, due to hormonal imbalances or treatments, can affect our emotional well-being.
Furthermore, hormonal imbalances are a source of physiological stress which is felt by our insular cortex, a part of our brain that senses our internal state. Similar to feeling down or fatigued at the beginning of a bad cold, we may sense hormonal imbalances and subconsciously allow it to affect our emotional state.
Although the exact reason for this association between conditions is unknown, many symptoms of PCOS, such as hirsutism, infertility, body weight fluctuations, and a general lack of control over one’s health and body can be frustrating and anxiety-provoking. Some studies have suggested that insulin resistance or higher androgen levels could be a factor that predisposes people with PCOS to develop mental health conditions.
Mental health can also be impacted by our energy levels throughout the day: if we are always exhausted, it is easier to fall into patterns of anxiety and depression. Fatigue, insomnia and other sleep disturbances, and brain fog are all common symptoms of PCOS. Consider the following facts about PCOS, our circadian rhythm, and sleep quality:
Selective serotonin reuptake inhibitors (SSRI), a major class of antidepressants, directly change our neurohormonal levels.
Recent studies have found that hormone replacement therapies (in which estrogen and other hormones may be supplemented) can have a reciprocal relationship with antidepressants; people taking antidepressants may be missing an underlying endocrine condition, and people treated with hormonal replacement therapy feel the effects not only physiologically but mentally as well (12). Additional studies have reported antidepressants’ interactions with estrogen receptors (13).
Androgen-blocking drugs are commonly used to treat endocrinological conditions or as an oral contraceptive yet they also affect our neurohormonal levels and mental health (14).
Common anti-androgen prescriptions include cyproterone acetate (co-cyprindiol or Diane™-35, Estelle™ 35 and Ginet-84™), drospirenone (Yasmin™, Yaz™) or dienogest (Valette™). Since hormonal fluctuations of estrogen, testosterone, and other hormones act on your brain as well as the rest of your body, blocking our androgens for physiological changes affects your mental health too. It is important to talk with your healthcare provider about the ways in which your treatments for either mental or endocrine conditions interact.
Be sure to speak with your care team if you are interested in learning more about the effect PCOS can have on our mental health, or if you are interested in learning more about additional support resources.