Sexual and reproductive health aspects in women with polycystic ovary syndrome: An integrative review

Abstract Background Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders in women worldwide, affecting their sexual and reproductive health (SRH). Objective This integrative review aimed to identify SRH aspects in women with PCOS by consolidating the findings from previous studies. Materials and Methods The present integrative review was conducted through an electronic systematic review search of 1052 manuscripts published from April 2000 to March 2020 using PubMed, SCOPUS, Web of Science, Embase, Google Scholar, MEDLINE, Science Direct, Ovid, and the Cochrane Library. After at least 2 researchers evaluated the articles based on the inclusion and exclusion criteria, 27 papers were accepted. The data were analyzed by thematic analysis. Results 9 main themes of SRH were obtained: 1) the impact of PCOS-related complications on reproductive health; 2) the lifelong effect of PCOS on reproductive patterns; 3) PCOS and adverse reproductive and pregnancy outcomes; 4) women's need for understanding complications; 5) the financial burden of the disease; 6) women's life experiences and quality of life; 7) sexual disorders; 8) psychological concerns and issues; and 9) femininity feelings and roles. Conclusion We were able to identify and categorize various aspects of SRH needs for women with PCOS. These categories can facilitate a more comprehensive assessment of SRH, including previously neglected areas. We suggest that these aspects should be considered in the health plans of women with PCOS.


Introduction
One of the key aspects of women's lives is sexual and reproductive health (SRH). According to the World Health Organization, reproductive health is defined as the Status of physical, mental and social well-being of the reproductive system (1). Reproductive health care includes lifelong health (from birth to death), and aims to help individuals and families improve health, empower women, and increase health care access (2,3).
SRH covers a wide range of care, including for maternal and newborn health, family planning, sexually transmitted infections (STIs) and HIV, reproductive system malignancies, infertility diagnosis and treatment, as well as reproductive health education, and male participation (4).
Today, the health and well-being of women, who consist half of the population, is considered as a human right, which has also an outstanding impact on health of both the family and society.
However, health rights, particularly women's SRH rights, are not yet fully recognized in many parts of the world. According to published statistics on the global burden of diseases in 1996, 22% of lives lost in women of childbearing age were due to neglect of SRH and related health problems such as unplanned pregnancy, STIs, and AIDS (5).
All over the world, in women of reproductive age, polycystic ovary syndrome (PCOS) is the most common endocrine disorder, which significantly affects reproductive health. Its prevalence in different regions varies between 2.2-26%. The syndrome is a combination of at least 2 of 3 conditions, including hyperandrogenism, chronic anovulation, and polycystic ovaries. It is often associated with insulin resistance and obesity (6). PCOS may affect the reproductive, metabolic, and endocrine systems, leading to menstrual disorders, endometrial hyperplasia, abnormal uterine bleeding, oligo-ovulation, infertility, and a significant reduction in quality of life.
Identification of SRH aspects is required to create a comprehensive and effective health plan (7).
Although some studies have evaluated some aspects of SRH such as infertility, sexual disorders, pregnancy complications, and quality of life for women with PCOS (8)(9)(10), no comprehensive study has evaluated all SRH aspects in women with PCOS.
In this article, we present an integrative review to identify SRH aspects in women with PCOS, as integrative review is a unique method that summarizes a variety of past theoretical and clinical studies to provide a more extensive understanding of a particular phenomenon or a health problem and a variety of relevant perspectives (11). This method emphasizes the emergence of new insights through a combination of evidence from studies conducted using a wide range of research methods.

Materials and Methods
The present study is an integrative review that assesses the SRH aspects of women with  (11). In this method, rigor of the studies, and relevance of data are scaled as either high, or low (a 2-point scale).
We used PRISMA flow diagram to perform the study steps. The 5 steps of integrated reviews were also used (12). So that we adapted the 5 stages of the integrative review study with the stages of the PRISMA flow diagram for systematic reviews.

Identification
The  (14), and the assessing the methodological quality of systematic reviews tool (AMSTAR) (15). In case of disagreement, a third researcher reviewed the article. This process is displayed in a PRISMA flow chart (12) (Figure 1).

Analysis
The focus of this analysis was to detect and combine the data of SRH aspects in PCOS  In the checklist, depending on the type of study and the methodological quality criteria, the evaluator answers 'yes' , 'no' or 'I cannot say' .
AMSTAR is a commonly used tool for assessing the methodological quality of randomized trials in systematic reviews. The instrument is an 11-item questionnaire that asks reviewers to answer 'yes' , 'no' , 'can't answer' or 'not applicable' with the scoring as: low quality (score 0-4); medium quality (score 5-8); and high quality (score 9-11) (17).

Data evaluation
The quality of the articles that did not have the routine format of questionnaires was evaluated by the research team in terms of the relationship between the content of the article and the purpose of the research, the type of journal, and the sources of the article. Weak, medium, and strong were the evaluation results.

Statistical analysis
The compilation of tables and comparative data analysis were conducted based on Whittemore and Knafl's suggestions (11). Qualitative thematic analysis was performed to develop themes from the categories and the repetitive patterns of the included articles (18). The analysis focused on identifying and categorizing SRH data of women with PCOS. A code framework was created to identify data patterns and separate distinct components. The codes were then divided into potential themes and examined to ensure that the overall code framework contributed to the study's purpose and content of the dataset.
Prevalent themes were identified and analyzed based on linkages of concepts (18). The research team members also discussed their ideas and interpretations during the process.

Results
All 27 selected articles were evaluated and scored by the research team according to the MMAT and AMSTAR criteria ( Table I) studies. As the study aim was to discover and consolidate knowledge rather than examining the evidence of impact, no articles were excluded just because of the study method.
Review -There was no routine format for questionnaire evaluation. Quality was assessed by the research team in terms of the relationship between the content of the article and the purpose of the research, the type of journal, and the sources of the article. Good

Rotterdam ESRHE/ ASRM sponsored PCOS consensus workshop group 2004 (27)
Report and consensus -There was no routine format for questionnaire evaluation. Quality was assessed by the research team in terms of the relationship between the content of the article and the purpose of the research, the type of journal, and the sources of the article. Medium

Norman et al., 2002 (28)
Review -There was no routine format for questionnaire evaluation. Quality was assessed by the research team in terms of the relationship between the content of the article and the purpose of the research, the type of journal, and the sources of the article. Good    and (9) femininity feelings and roles. Each theme is explained below. Table II lists the extracted themes from the selected articles, and the aims of the studies that investigated these themes.  The fertility-related information needs and preferences of women with PCOS        these include physical challenges (e.g., feeling unhealthy), social challenges (e.g., feeling old and disabled), and emotional challenges (e.g., worrying about aging with a chronic illness). Therefore, there is a need for comprehensive health care and psychological support for the treatment of PCOS in adolescents and young women in the early decades of reproductive ages (36). Women need specific support from health care workers to reduce anxiety and improve disease management by changing their lifestyle (43). Designing a comprehensive health program can improve women's mental health. One study also showed that a mental health program for women with PCOS offered by a multidisciplinary team was able to improve fertility outcomes while also being cost-effective (30).

Discussion
In this study, from 27 selected articles, 9 main themes on SRH aspects in women with PCOS were Considering the prevalence of this disease, prevention is important and it is recommended that health officials provide preventative programs such as disease screening programs for women and girls with obesity and hirsutism (32). One study reported that globally 1 in 5 women of childbearing age with obesity and hirsutism is affected by PCOS, and that the disease has clinically significant consequences for fertility, including infertility, hyperandrogenism, and hirsutism (19). Menstrual disorders and infertility have direct effects on reproductive health. Pregnancy and its related care are often affected by infertility and its consequences.
One study showed that PCOS had profound This study showed adverse pregnancy outcomes in women with PCOS such as gestational diabetes, preeclampsia, preterm labor, fetal death, neonatal death, low Apgar scores, meconium aspiration, macrosomia, and large for gestational age and small for gestational age newborns (22). These complications can be reduced by providing appropriate prenatal care, care during and after delivery, and treatment of obstetric complications.
One study showed that PCOS was associated with maternal and neonatal complications such as: miscarriage, hypertensive disorders, gestational diabetes, and preterm labor; and also higher risk  (49). Therefore, women need to receive special care to reduce their anxiety and improve their disease management (43).
Women with PCOS are also more susceptible to mood disorders and depression (41). Studies have suggested that PCOS can be associated with psychiatric disorders, and it is recommended to consider these disorders in the management of PCOS (50,51). Therefore, after PCOS diagnosis, it is essential to screen for psychological disorders and refer to appropriate counseling centers, if needed (52).
Also, this study looked at the role of femininity in women with PCOS. It was observed that PCOS symptoms can negatively affect patients' roles and responsibilities as women and mothers, and reduce their public activities (50). The most important issue for women with PCOS is treating the physical complications, and usually their social roles and femininity are overlooked. Therefore, in assessing SRH needs, it is imperative to consider feelings of femininity and perceptions of roles of these women.

Conclusion
In many health systems designed to provide SRH services, women with PCOS are not given special attention, and their needs are assessed similarly as women without PCOS.
In the present study, it was shown that the complications of this disease affect SRH aspects of women throughout their lives from the embryonic stage to old age. Complications of pregnancy and childbirth can include preeclampsia, preterm delivery, gestational diabetes, and neonatal complications (20). The disease can also have adverse effects on women's sexual functions. Some studies have shown effects of complications such as hirsutism, obesity, skin and hair problems, and infertility on sexual function. Therefore, women with PCOS have different SRH needs, which should be specifically considered in the service delivery system (26).
PCOS and its complications cause a high financial burden that is often ignored in women's SRH needs.
Thus, more research is needed to assess the costs in different countries. Also, PCOS can affect women's mental status; the psychological complications are often hidden and ignored. Because of the life-long nature of PCOS, affected women may need different care compared to the general population in each stage of their lives, and health systems should provide tailored services to these women (20,49).
To meet the SRH needs of women with PCOS, the researchers of this study suggest that health services for these women should be presented as a complete package of treatment based on the actual needs of the women.