Dissatisfaction with body image is one of the major causes for psychological disorders even in a healthy population; most women affected by PCOS are overweight, and having a high BMI exposes them to several appearance-related challenges.

Some studies showed that PCOS women have lower quality of life and overweight was the largest contributor to poor QoL [4]. In fact, health-related quality of life questionnaires in women with PCOS have shown that excess weight and difficulties with losing weight are the foremost concerns [5].

Moreover, by using PCOSQ (Health-Related Quality of Life Questionnaire for Women with Polycystic Ovary Syndrome), it was demonstrated that higher levels of BMI related with lower scores (reported by respondent), which is indicative of several weight-related concerns [6].

Personal negative judgments regarding own body appear to be associated with the difficulty to begin close and romantic relationships.

Women with PCOS report that they are not happy with the way they look or the way that clothes fit them and consequently do not feel their body is sexually appealing [8]: these feelings are negatively associated with self-esteem, body satisfaction, and fear of negative appearance evaluation [9].

In fact, a poor body representation in PCOS women may be conditioned by cultural influences as it has been shown that android fat pattern, commonly associated with PCOS, is considered unattractive in many cultures [10, 11].

Women with PCOS recognize excessive hair growth (especially on face) as the second most severe symptom negatively affecting on their life satisfaction [12].

Some women, in fact, describe themselves using masculine terms such as “beard” or “mustache,” and they are frustrated because they look at their bodies as a failure of their femininity [13, 14].

The presence of facial hair is one of the most essential and visible differences between men and women: hair on a female face reflects a symbolic transgression between the two genders [15].

As shown in a qualitative study, hirsute women feel “slaves of their own body” and describe this condition as a “prison” [16]. Moreover, looking in the mirror very often could represent an obsessive-compulsive behavior [17].

Characteristic symptoms of PCOS occur during a life period in which relationships, marriage, and having a child play an important role: for this reason, changes in femininity are likely to mean an increased risk of psychological distress [7].

As any cause of infertility, even PCOS could lead to exaggerated emotional states depending on lots of variables such as period of time spent in trying to conceive and number of attempted therapies.

Several factors predicting the impact of PCOS-associated infertility upon HRQoL (health-related quality of life) have been identified: PCOS women who had been pregnant but had miscarriage experience reported the lowest scores on the infertility field, exceeding those who had been unsuccessful in having pregnancy [6].

Some patients are infertile and are subjected to social pressure due to the importance given to having children by the society.

Having a partner who supports the hope of having a child was found to be a protective factor and improves the emotional well-being of PCOS patients [18].

Moreover, according to a study, even adolescent girls with PCOS are 3.4 times more likely than healthy girls to be “worried about their ability to become pregnant in the future” compared to the controls; however, this fear was not associated with odds of having sexual intercourse [19, 20].

Menstrual irregularities are associated to low feminine identity too [13]. Oligo-/amenorrhea can have important social consequences, especially in many Muslim backgrounds. For example, the tenets of Islam decree that menstruating women are not allowed to pray [20]. If a woman prays every day, without the expected monthly stop of 4–5 days, her social entourage will be aware that she is experiencing menstrual irregularities [21].

PCOS has also a negative effect on sexual functioning, even when data are adjusted for BMI; the main reason is the low self-esteem and constant concerns about their appearance. Based on the study of Elsenbruch et al. “women with PCOS did not differ from others in the frequency of their sexual activity and sexual thoughts; they were less satisfied with their sexual life and found themselves less attractive thinking that their partners find them less attractive and remain sexually unsatisfied while being with them” [7].

Moreover, in another study a substantial portion of women with PCOS reported that they most often took the initiative to have sexual intercourse in the relationship [22, 23]. Could this be related to the increased testosterone levels in PCOS women? No associations were found. An alternative psychological explanation is that some women with PCOS felt that their partners were not attracted by them [7].

Mood disorders include major depressive disorder (MDD), dysthymic disorder, and depression not otherwise specified based on DSM-IV [24].

In healthy people, depression can cause or exacerbate clinical symptoms such as fatigue, poor sleep, and changes in appetite and weight. In those with chronic illness, depression can have more insidious consequences, influencing the expression and course of disease [25].

Several studies have been investigating the association between PCOS and depression. The result is that PCOS women reported more depressive symptoms compared with the control group [7, 26] and scored above average on questionnaires assessing depression [27, 28].

The prevalence of depression in women with PCOS is high, ranging from 28 to 64 % [29–31]. Studies found that 14 % of women suffering from PCOS reported suicidal ideation. This percentage is high as what has been reported from other chronic medical conditions and much higher than in the general population [32].

Despite this, there are discordant opinions about the real cause: neither androgenization nor excessive hair growth showed significant correlation with depression [27]. In fact, it was not observed any significant differences in total or free testosterone levels or in the adrenal androgen DHEAS between depressed women with PCOS and non-depressed women with PCOS [33].

Two-thirds of women with PCOS show weight problems, but it is not properly correlated only to PCOS: in fact, high BMI might increase depression in the normal population as well [34–36].

Some studies found depressed women with PCOS to have a higher evidence of insulin resistance and impaired fasting glucose than PCOS women without depression [27, 33].

There are plausible physiological connections between depression and insulin resistance; in fact, depression has been associated with increased cortisol, amplified sympathetic activity, decreased central nervous system serotonin, and increased inflammatory markers: these features are also associated with insulin resistance [37].

Depression is also associated with behaviors that worsen insulin resistance, including unhealthy eating and physical inactivity. These findings may explain why depression predisposes to diabetes [38].

In view of all these data and because the peak incidence of depression is during the reproductive years, gynecologists have to be able to identify and treat women with PCOS who have depression.

According to the DSM-IV, diagnostic criteria for GAD (generalized anxiety disorder) include excessive anxiety and apprehension about events or activities, occurring more days than not, for at least 6 months; abnormal anxiety becomes a problem when it occurs without any recognizable motivation or when the stimulus does not warrant that kind of reaction [39].

Anxiety symptoms could be identified in one-third of PCOS patients, especially social phobia [32, 35, 40]. It has been associated mainly with hirsutism [17], acne [41], obesity [42], and infertility [43].

The prevalence of anxiety in women with PCOS ranges from 34 to 57 % [31, 44].

Fears reported by hirsute women are mainly categorized as “social phobia” or anxiety-evoking situations, such as meeting strangers, attending parties, shopping, and mixing at work [6].

PCOS women with higher anxiety scores showed significantly elevated insulin resistance and FAI (free androgen index) values than PCOS with lower anxiety score, independently out of BMI [45].

Some authors have suggested that adolescents with PCOS are at higher risk for anxiety symptoms related to the clinical signs of hyperandrogenism. In a study of hirsute 13–18-year-old girls, anxiety was diagnosed in 26 % compared with 10 % in the control girls [46]. Furthermore, successful treatment of hirsutism leads to a reduction of time spent on hair removal with a consequent improvement in anxiety score [47].

The risk of developing coexistent depression and anxiety in women with PCOS is unknown [39]. An interesting study found that 15 % of PCOS patients had coexistent anxiety and depression. Coexisting anxiety in depressed patients may worsen the outcome increasing the risk of suicide, worsening overall symptoms, conferring a poorer response to treatment, increasing the number of medically unexplained symptoms, and increasing functional disability [48].