Letters to the editor |
Reply: Incorporating qualitative approaches is the path to adequate understanding of the psychosocial impact of polycystic ovary syndrome
1 Department of Medical Psychology, University Hospital of Essen Medical School, Essen, Germany 2 Endokrinologikum Ruhr, Center for Metabolic and Endocrine Diseases, Bochum, Germany 3 Division of Endocrinology, Department of Medicine, University Hospital of Essen Medical School, Essen, Germany
4 To whom correspondence should be addressed at: Department of Medical Psychology, University of Essen, 45122 Essen, Germany. E-mail: sigrid.elsenbruch{at}uni-essen.de
Sir,
We thank Drs Azevedo and Moreira for their comments on our article addressing emotional distress and the quality of life in women with polycystic ovary syndrome (PCOS) and would like to address and further comment on several interesting aspects that were raised:
- We agree that there are different methodological approaches to address the impact of the physical features characterizing PCOS (e.g. obesity, hirsutism, acne and alopecia), the hormonal and metabolic aspects (i.e. hyperandrogenism and insulin resistance) as well as the situational (e.g. infertility) concomitants of the diagnosis on emotional well-being and the quality of life in affected patients. Clearly, the interactions between the medical and psychological aspects of PCOS are exceedingly complex, which are at least in part due to large inter-individual differences in symptom constellation on the one hand, and individual coping strategies and the individual social situation on the other hand. Thus, we feel that different approaches are possible and in fact necessary to expand our yet limited understanding of the psychological aspects of PCOS. Mixed methodology combining quantitative and qualitative methods may reveal complementary results. We are looking forward to yet unexplored ways to characterize and, in the end, help these women cope with PCOS and its consequences.
- Apparently, Drs Azevedo and Moreira come to similar conclusions as other groups using qualitative methods as to which factors are most important in the reduction of the quality of life in PCOS patients, namely obesity and infertility. With regard to the emotional consequences of these symptoms, the authors also describe findings which are similar to our own data, i.e. the feeling of sadness which in our set of measures is reflected by increased scores on the SCL-90-R’s scale depressiveness, and the feeling of ‘social isolation’, reflected by increased scores on the SCL-90-R’s scale ‘interpersonal sensitivity’ and a greater mean score on the visual analogue scale ‘fear of social contacts’ (Elsenbruch et al., 2003
). Certainly, it is important in a clinical context to explore PCOS strictly on an individual basis, but for larger samples, quantitative measures are critical to generate results that can be generalized and are statistically interpretable. Especially in the context of treatment studies, it is exceedingly important to use quantitative measures to allow statistical assessment of treatment effects on psychological and quality-of-life measures as additional outcome variables (Hahn et al., 2006).
- Indeed, we agree that it would be particularly important to incorporate and address aspects of the social context into future studies on the psychological sequelae of the diagnosis. For example, it is well known from other medical conditions that perceived social support is a critical determinant of patients’ vulnerability to life stress. Clearly, an effective social network providing instrumental but particularly emotional support is one of the most important coping strategies and acts as a stress ‘buffer’, and we would expect this to play an important role in the ability of patients to cope with the diagnosis of and the symptoms associated with PCOS. Unfortunately, thus far, nothing is known regarding coping strategies in general or social support in particular in PCOS, and qualitative as well as quantitative methods may close this gap. A hint at the role of social context relevant to the emotional ‘vulnerability’ of PCOS patients from our own data is the finding that in our sample, patients reporting either the current wish to conceive or anxiety to remain without a child do not (against what one would expect) have more pronounced reductions in the quality of life (Hahn et al., 2005). Interestingly, further inspection of the data showed that a significantly increased percentage of these women were married or had a steady partner. These data would suggest that having a partner who supports the wish for a child constitutes a protective factor which improves the emotional well-being of patients. Overall, in all research on stress and health, it is important not only to address the risk factors (in the case of PCOS: obesity, hirsutism, etc.) but also to incorporate protective factors (i.e. effective coping strategies, e.g. reflected by the ability to have a healthy relationship in spite of the clinical symptoms of PCOS).
- We fully agree and have previously discussed (Hahn et al., 2005) the pros and cons of using disease-specific versus generic instruments to address quality of life. Disease-specific instruments more directly address the specific problems of patients—in the case of PCOS, acne, infertility, obesity etc. On the contrary, the findings cannot be compared to samples affected by other ailments and their healthy controls, which precludes an assessment of the relative impact of the specific problems. We chose generic instruments because (a) we aimed to compare PCOS patients with normative values and (b) because no validated disease-specific instrument exists for use in German patients. Ideally, it would be best to use both sets of measures in one study.
- The notion that PCOS constitutes a problem of impaired female identity is interesting and has been discussed in several articles on the psychological impact of PCOS. Although this concept is intriguing and at first glance convincing, a more in-depth analysis raises the question of how to define, validate and quantify ‘feminine identity’. Here, qualitative methods may add to our understanding of this intriguing concept, which deserves further study.
References
Elsenbruch S, Hahn S, Kowalsky D, Offner AH, Schedlowski M, Mann K, Janssen OE. (2003) Quality of life, psychosocial well-being, and sexual satisfaction in women with polycystic ovary syndrome. J Clin Endocrinol Metab 88:5801–5807.
Hahn S, Janssen OE, Tan S, Pleger K, Mann K, Schedlowski M, Kimmig R, Benson S, Balamitsa E, Elsenbruch S. (2005) Clinical and psychological correlates of quality-of-life in polycystic ovary syndrome. Eur J Endocrinol 153:853–860.
Hahn S, Benson S, Elsenbruch S, Pleger K, Tan S, Mann K, Schedlowski M, van Halteren WB, Kimmig R, Janssen OE. ( March 20, 2006) Metformin treatment of polycystic ovary syndrome improves health-related quality-of-life, emotional distress and sexuality. Hum Reprod (Epub ahead of print).
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