Polycystic ovary syndrome (PCOS) is a complex reproductive endocrinological disorder that affects 6–20% of women worldwide, which persists throughout the reproductive lifespan [1]. At the same time, hormonal imbalance results in various clinical manifestations such as oligomenorrhea or amenorrhea, hirsutism, acne and infertility [2], the Insulin resistance (IR) and hyperinsulinemia (HI) leads to various metabolic derangements like diabetes, obesity, higher dyslipidaemia, etc. The disease is diagnosed using the modified Rotterdam criteria 2023, according to which at least two of the following parameters must be present: oligo-ovulation/anovulation, hyperandrogenism, and polycystic ovaries on ultrasound (PCOM) [3]. Once diagnosed, the condition is managed with a combination of lifestyle modifications (diet, exercise, and mental health), hormonal pills, anti-androgen therapy, metformin, ovulation induction, and artificial reproductive techniques if required [4].

Hyperandrogenism is the foremost manifestation, marked by an overproduction of androgens originating from the ovaries. These symptoms, like hirsutism, acne and alopecia, may create body image issues leading to anxiety and depression. However, PCOS per se increases the chances of getting anxiety and depression disorders. The hormonal imbalances characteristic of PCOS can contribute to mood disturbances, amplifying the risk of depressive symptoms and anxiety disorders [5].These symptoms often diminish their sense of femininity and physical satisfaction, leading to sexual dysfunctions and overall mental health and ultimately leading to a poor quality of life [6, 7].

Beyond the physiological factors, the emotional toll of managing a chronic condition, coupled with societal pressures and potential fertility concerns, can further contribute to the heightened prevalence of depression and anxiety among those with PCOS. Recognizing and addressing these mental health issues is critical to promoting a comprehensive approach to PCOS treatment [8].

Emotion regulation refers to the influence individuals exert on the production, experience, and expression of emotions [9]. This process encompasses not only changing emotions themselves but also other psychological factors such as cognition, behaviour, and social interactions [10]. Therefore, it is essential to provide effective emotional management to treat these psychological and emotional issues in PCOS patients.

To effectively address the psychological distress and emotional challenges faced by women with PCOS, there is an urgent need to develop feasible, patient-friendly intervention programs that focus on enhancing mental well-being and improving body image, leading to a holistic approach toward these women.

The primary objective of this study was to comprehensively examine and analyzed the clinical manifestations, along with the physical, mental health and emotional well-being aspects of quality of life in sub-fertile women with PCOS in the rural Indian population.

This was an observational study conducted from January 2023 to July 2025 among women aged 18–40 years diagnosed with PCOS, included based on the Rotterdam criteria 2023. A total of 2200 participants were enrolled in the study. The research was carried out in rural Indian sub-fertile populations to assess the symptoms of mental health and emotional well-being in individuals diagnosed with polycystic ovarian syndrome (PCOS).

Women who have crossed their reproductive age (> 40 years), including postmenopausal women, might introduce confounding variables related to hormonal changes associated with menopause and Co-existing endocrine disorders (e.g., thyroid dysfunction, Cushing's syndrome). Severe psychiatric illnesses already under treatment were excluded from the study.

The study was approved by the Medical Ethics Committee of the Hospital (VPIMS/IEC/098/2023). All patients gave informed consent to use the questionnaire for clinical data in this study.

For data collection, a self-constructed questionnaire was used during the first visit for consultation at our centre. The questionnaire, which had been meticulously validated by professionals, consisted of a total of 10 questions, in Hindi language. These questions were designed to assess the participants' physical consciousness and their anxious and depressing thoughts, providing a comprehensive view of their mental and emotional well-being.

The following questions and their answers are discussed in the paragraphs below.

Do you think you look good? Out of 2000 patients, 1368(68.4%) felt Good, 368(18.4%) felt they looked very good, only 70(3.5%) considered themselves Average looking, and 194(9.7%) felt they didn't look good at all. A strong majority (86.8%) perceive themselves as attractive or better, indicating a generally positive body image in this population, with an inferiority Complex about Body Shape. Out of 2000 patients, 1384 (69.2%) felt comfortable with their body shape, while 613 (30.8%) felt inferior about their body shape.

If so, how do you feel about this? 946 (47.3%) Patients felt "I am alright,146 (7.3%) felt "I am so skinny," reflecting concerns about being underweight, and 908 (45.4%) felt "I am so fat and shapeless," expressing strong dissatisfaction and negative body image. This bimodal pattern reflects body dissatisfaction and internal conflict, which are common in appearance-related issues. (Figure-2)

Sleep Quality: Out of (n = 2000) Patients, 1464 (73.2%) were sleeping well, while 536 (26.8%) experienced poor sleep quality. More than one-quarter of the participants suffered from poor sleep, which is a well-recognized indicator of anxiety, depression, and body dissatisfaction. Comfort in Crowded Places (Social Discomfort): Out of 2000 Patients, 864 (43.2%) felt comfortable in crowded places, whereas 1136 (56.8%) felt discomfort. Over half of the participants experienced unease in social settings, suggesting elevated social anxiety, particularly among those with heightened appearance concerns or body image dissatisfaction. Sense of Meaningless Life: Out of 2000 Patients, 726 (36.3%) had a sense of meaninglessness in life, while 1274 (63.7%) did not share this perception. Over one-third of respondents expressed feelings of hopelessness or purposelessness, which are often associated with body image dissatisfaction and depressive symptoms. Emotional Reactivity (Crying Easily): 1286 (64.3%) expressed their emotional reactivity in the form of crying easily whenever they felt any discomfort in their surroundings, while 714 (35.7%) had no such problem. Nearly two-thirds of respondents displayed heightened emotional sensitivity, which is often linked to body dissatisfaction and anxiety-related symptoms and Subfertility. Thoughts of Ending One's Life (Suicidal Ideation): Out of 2000 Patients, 410 (20.5%) reported experiencing suicidal thoughts, while 1590 (79.5%) did not. It has been observed that approximately one in five Patients experienced suicidal ideation, reflecting a considerable mental health burden. Consistent with PCOS-related body image issues, Anxiety and Depression. (Figure-3)

PCOS is characterised by intricate features, rendering its diagnosis challenging. Polycystic Ovary Syndrome (PCOS) significantly influences the mental and emotional well-being of affected women [11, 12].The chronic nature of the disorder, coupled with its physical manifestations such as obesity, hirsutism, acne, and menstrual irregularities, can contribute to low self-esteem and body image dissatisfaction. Emotional stress often arises from infertility concerns, which is a frequent and distressing complication of PCOS [13].

The present study highlights a significant impact of mental health concerns among women with Subfertility and PCOS, with notable effects on their emotional, social, and potentially financial well-being. In our study, Social discomfort was evident in more than half of the participants, reflecting heightened social anxiety and avoidance tendencies. This observation may be linked to body image dissatisfaction, which is directly related to their perception of femininity [14].

PCOS women with fertility challenges often perceive themselves as socially stigmatized, particularly in cultures where fertility is strongly tied to social identity and marital expectations. Social withdrawal can, in turn, intensify feelings of isolation and hopelessness, further impairing mental health [12].

In our study, women with PCOS followed the same trend as more than half of the participants, n = 1136(56.8%) experienced unease in social settings, suggesting a higher prevalence of social anxiety. Chronic emotional distress has been associated with poor sleep, reduced treatment adherence, hormonal imbalance, and impaired decision-making, which can further hinder fertility prospects [15]. It is well evident in our study where Out of (n = 2000) Patients, 536 (26.8%) experienced poor sleep quality (Figure-3).

Women with PCOS are reported to have a higher prevalence of anxiety, depressive symptoms, and emotional distress, which may be further exacerbated by negative body image, poor sex life, social stigma and isolation. Poor sleep quality, mood swings, and irritability are common, and many patients experience a sense of hopelessness or helplessness regarding their condition [16]. Over one-third of respondents n = 726 (36.3%) experienced feelings of hopelessness or a lack of purpose, and felt that their life was meaningless, while, 1274 (63.7%) women did not share this sentiment despite facing the same challenges. 1286(64.3%) and 714(35.7%) felt like crying over little things. This emotional reactivity is often associated with body dissatisfaction and anxiety-related symptoms.

Thoughts of ending One's Life (Suicidal Ideation): Approximately one in five participants (410/2000 = 20.5%) expressed suicidal ideation, indicating a substantial mental health burden. In line with previous body image research, suicidal thoughts tend to be more prevalent among individuals experiencing significant appearance-related distress, dissatisfaction and infertility [17].

The outcomes derived from our study align with a study published in 2024, where they found a positive correlation between mental and emotional well-being and various symptoms of PCOS, like weight gain, hirsutism, and menstrual irregularity [18].Moreover, the challenges associated with PCOS extend beyond its primary symptoms, incorporating distressing elements such as coexisting conditions like diabetes, and complex complications like miscarriage and infertility. The intricate nature of managing and treating these multifaceted aspects significantly contributes to the overall stress experienced by women [18].

A study by Begum and colleagues emphasised the importance of addressing poor health-related quality of life (HRQOL) in PCOS patients beyond conventional treatment for physical symptoms. This approach involved utilizing interviews and open-ended questions to allow patients to express concerns related to their QOL[19].The findings underscored the intricate interplay of physical, psychological, and social aspects in a woman's life, shedding light on their discomfort, which in turn had notable mental repercussions [20].

The psychological burden is often compounded in rural populations, where awareness and access to mental health support are limited, leading to delayed interventions and increased psychosocial impact. Addressing the mental and emotional aspects of PCOS through counselling, lifestyle modifications, and support groups is crucial for improving overall quality of life and treatment outcomes [21].

Integrating mental health screening and support into fertility care is, therefore, not optional but essential. Women undergoing ART or living with PCOS should receive psychological counselling, stress-reduction support, and body image interventions as part of comprehensive, person-centred care. Improving emotional well-being not only enhances quality of life but may also improve clinical outcomes in fertility treatment [22, 23].

Improving mental and emotional well-being in women experiencing Subfertility or PCOS requires a multidimensional approach that addresses psychological, social, and lifestyle factors. Psychological interventions such as cognitive behavioural therapy (CBT) and mindfulness-based stress reduction (MBSR) have been shown to reduce anxiety, depressive symptoms, and emotional reactivity by enhancing coping skills and resilience [24, 25].

Social support is another crucial protective factor; involving partners and family members in counselling sessions, encouraging participation in peer support groups, and fostering community-based awareness programs can reduce isolation and stigma. Lifestyle modifications—including regular physical activity, balanced nutrition, and improved sleep hygiene—play a key role in boosting self-esteem, regulating mood, and enhancing overall well-being [26]. Furthermore, ensuring accessible and affordable mental health services within fertility clinics can address psychological distress early. In contrast, public health policies aimed at reducing stigma and financial burden can provide long-term societal support. Integrating these strategies within a holistic, multidisciplinary care model is likely to improve not only emotional health but also treatment outcomes and quality of life for women affected by these conditions.

Polycystic Ovary Syndrome (PCOS) significantly affects the emotional and mental well-being of sub-fertile women in rural India. Beyond its clinical manifestations, the condition contributes to heightened psychological distress, low self-esteem, and social isolation due to infertility-related stigma and limited awareness. This study underscores the urgent need for holistic, multidisciplinary management strategies that extend beyond medical management to include lifestyle modifications and comprehensive mental health support, counselling, and community-based education, ultimately leading to social empowerment, particularly in underserved rural settings. Addressing the emotional and psychological dimensions of PCOS is also essential for improving the overall quality of life and reproductive outcomes in this vulnerable population.