The association between body image and well-being in polycystic ovary syndrome: a mixed-methods study

Objective: To examine body image (BI) concerns in women with polycystic ovary syndrome (PCOS) by comparing perceptions with normative data, assessing links with psychological distress, clinical features, disordered eating, and quality of life (QoL), and identifying body image cut-offs that predict psychological risk.

Design: Mixed-methods observational study conducted in the United Kingdom (June 2023-October 2024).

Methods: Women with PCOS (n=171) completed validated questionnaires assessing BI (Multidimensional Body-Self Relations Questionnaire - Appearance Scale), depression, anxiety, disordered eating, and QoL; 41 also participated in semi-structured interviews. Moderation by ethnicity and socioeconomic status (SES) was examined.

Results: Women with PCOS reported greater BI-distress than normative data, driven by elevated body mass index (BMI) and hirsutism. Poorer BI was linked to higher depression, anxiety, disordered eating, and reduced QoL. ROC-analyses identified self-classified weight scores (SW)≥4.25 as the cut-off for depression and overweight preoccupation (OP)≥2.88 for anxiety. In adjusted models, higher SW scores predicted nearly fivefold greater depression risk, while elevated OP scores conferred a fourfold higher anxiety risk and doubled disordered eating risk. Together with BMI, OP and SW predicted most PCOS-QoL domains, with the strongest effects in weight-related QoL. Socioeconomic deprivation amplified OP effects on disordered eating, while ethnicity showed minimal influence. Qualitative findings echoed these results, with weight gain, hirsutism, negative diagnostic experiences, and social withdrawal emerging as key distress drivers.

Conclusion: BI concerns are central to psychological morbidity and reduced QoL in PCOS. Establishing OP and SW cut-offs enables early risk stratification, while acknowledging SES influences may support equitable, patient-centred care.