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Article

The Prevalence of Polycystic Ovary Syndrome and Fibromyalgia in Women with Borderline Personality Disorder and Their Association with Childhood Abuse

by
Eveline Mu
1,2,*,†,
Tia Tsinanis
1,2,†,
Kathleen de Boer
1,2,
Elizabeth H. X. Thomas
1,2 and
Jayashri Kulkarni
1,2
1
HER Centre Australia, Department of Psychiatry, School of Translational Medicine, Monash University, Melbourne, VIC 3004, Australia
2
Multidisciplinary Alfred Psychiatry Research Centre, Department of Psychiatry, Alfred Health, Melbourne, VIC 3004, Australia
*
Author to whom correspondence should be addressed.
†
These authors contributed equally to this work.
Women 2024, 4(4), 377-386; https://doi.org/10.3390/women4040029
Submission received: 7 August 2024 / Revised: 11 September 2024 / Accepted: 22 October 2024 / Published: 23 October 2024
Versions Notes

Abstract

:
Childhood abuse is a significant factor in the development of borderline personality disorder (BPD) and many physical health disorders, including polycystic ovary syndrome (PCOS) and fibromyalgia. This study aimed to examine the prevalence of PCOS and fibromyalgia in women with BPD compared to the general population. Additionally, it compared the prevalence of these conditions in women who experienced different types of childhood abuse (emotional, physical, or sexual). Participants were identified from the Multidisciplinary Alfred Psychiatry research centre’s Women’s Mental Health Clinic database, including 150 women diagnosed with BPD. Clinicians collected information on PCOS, fibromyalgia, and trauma history. Results showed higher rates of PCOS (17.3%) and fibromyalgia (8.7%) in women with BPD compared to general population samples. Emotional abuse was associated with the highest PCOS prevalence (22.8%), while co-occurring physical, sexual, and emotional abuse was linked to the highest fibromyalgia prevalence. These findings highlight the significant prevalence of PCOS and fibromyalgia in women with BPD and their association with childhood abuse.

1. Introduction

Borderline personality disorder (BPD) is a relatively common mental health condition estimated to impact 2.7% of women in Australia [1]. BPD is characterised by a range of symptoms, including an unstable self-image and difficulties regulating emotion, controlling impulses, and maintaining stable interpersonal relationships [2]. While the amalgamation of these symptoms may lead to a diagnosis of BPD, the aetiology of the disorder is still somewhat undefined, but abuse during childhood (physical, sexual, or emotional) seems to be a significant contributing factor [3]. Several studies have established a significant relationship between exposure to childhood abuse and BPD [4,5], and some research suggests a causal relationship [6].
It has previously been established that exposure to childhood maltreatment is related to an increased risk of developing several physical disorders [7], including fibromyalgia [8], polycystic ovary syndrome (PCOS; [9]), and gynaecological issues [10]. Some studies have revealed that emotional abuse is most strongly correlated with several health conditions, such as fibromyalgia [11], compared to other forms of abuse.
Fibromyalgia is a chronic disorder characterised by musculoskeletal pain [12], with psychological and physical distress often being the trigger for the development of symptoms [13]. Recent research has suggested that the experience of childhood abuse may play an important role in the development of fibromyalgia [14,15]. A systematic review found significant relationships between fibromyalgia and physical and sexual abuse in childhood and adulthood, though this relationship was not found in the case of emotional abuse [16]. When compared with controls, fibromyalgia patients had a higher rate of personality disorder diagnoses, with the rate significantly higher for BPD diagnosis [17]. Additionally, studies examining the prevalence of psychiatric disorders in fibromyalgia patients determined that 27% suffer from comorbid BPD (BPD; [18]) and post-traumatic stress disorder [19].
Like fibromyalgia, PCOS is associated with the experience of childhood abuse and BPD [20]. PCOS is an endocrine disorder characterised by infertility, obesity, menstrual dysfunction, acne, metabolic syndrome, and hirsutism [21]. Prior research has found that women with BPD have a higher proportion of polycystic ovaries (30.4% vs. 6.9%) compared to mentally healthy controls [22,23]. Further, Tay et al. [9] found a high prevalence of childhood abuse in a community sample of women with PCOS, with 19.3% reporting adverse childhood experiences. More recently, a significant association between emotional and physical abuse and PCOS was found [24]. However, when evaluated in the context of all maltreatment subtypes, only emotional abuse remained associated with symptoms of PCOS.
The understanding of the mechanisms that may link childhood maltreatment to the development of fibromyalgia and PCOS is not well established. Some research suggests that an imbalance in the hypothalamic-pituitary-adrenal (HPA) axis may contribute to the development of these disorders. While stress exposure in the short term can lead to adaptation and growth, exposure to chronic stress can have an enduring impact on physical health. The HPA axis activates an array of physiological and behavioural processes in response to stress, such as the modulation of metabolism and brain function [25]. Overstimulation of the HPA axis due to chronic stress, for example, childhood maltreatment, can result in abnormal neurobiological functioning. One component of the HPA axis is cortisol, a glucocorticoid that plays a role in many biological systems, such as the immune, nervous, cardiovascular, and musculoskeletal systems [26]. While no definitive cortisol regulation pattern has been established in adults who have experienced childhood maltreatment, adverse physical symptoms have consistently been linked to aberrant HPA axis activity [27].
The development of PCOS has also been associated with atypical HPA axis activity, with the experience of childhood abuse postulated to contribute to its development in women [23]. Hyperactivation of the HPA axis can result in hyperandrogenism, a defining feature of PCOS. When the HPA axis is stimulated (i.e., in the case of chronic stress), the adrenal glands secrete androgens in conjunction with cortisol. Thus, chronic stress likely activates the HPA axis, resulting in increased androgen production and, consequently, the elevated testosterone levels that are characteristic of many women with PCOS [28]. Hyperandrogenism is responsible for the presentation of a range of clinical features, including impaired folliculogenesis, acne, and hirsutism [28].
While prior research has demonstrated that women with a history of childhood abuse concomitantly suffer from a range of physical health disorders, limited research has determined whether prevalence rates of certain physical disorders are higher in such individuals compared to the general population. This is an important area of research, given that the discomfort and distress associated with these disorders may contribute to an exacerbation of mental health symptoms [29,30,31]. While the individual relationships between childhood abuse and physical symptoms in an adult BPD sample have been established, little is known about the associations between childhood abuse and formally diagnosed physical health disorders, such as fibromyalgia and PCOS, in women with BPD. Furthermore, the prevalence of stress-related disorders in women with BPD who have experienced specific forms of abuse has seldom been explored [32,33].
The current study aimed to investigate whether the prevalence rates of PCOS and fibromyalgia were higher in women with BPD compared to the general population, and to explore the prevalence rates of PCOS and fibromyalgia across abuse types. We hypothesised that women with BPD would exhibit higher prevalence rates of PCOS and fibromyalgia compared to the general population. Additionally, we hypothesised that within the BPD sample, women who reported experiencing childhood emotional abuse would have higher prevalence rates of PCOS and fibromyalgia compared to those who reported childhood sexual or physical abuse.
Given the exploratory nature of the study, a further aim was to compare the prevalence rates of PCOS and fibromyalgia in women with BPD who experienced emotional abuse exclusively to those who experienced emotional abuse in addition to other forms of abuse.

2. Results

2.1. Demographic Data

A total of 150 women were identified from the Multidisciplinary Alfred Psychiatry research centre’s (MAPrc) Women’s Mental Health Clinic (WMHC) database for this study. The mean age of participants was 39.00 (SD = 11.49). However, age data was unavailable for 11 participants, leaving 139 participants with complete age information.

2.2. Comparison of PCOS and Fibromyalgia Prevalence Rates in Women with BPD Observed in the Present Study to the General Population

As indicated in Table 1, the prevalence of PCOS diagnoses in women with BPD (17.3%) observed in the present study is substantially higher than the prevalence rates of PCOS in the general Australian (5.6% and 8.7–11.9%; 5.6% and 8.7–11.9% [34,35]) and Spanish (6.5%; 6.5% [36]) populations. Similarly, the prevalence of fibromyalgia diagnoses in women with BPD (8.7%) is notably higher than the prevalence rates of fibromyalgia in the general Swedish (1.2%; 1.2% [37]), Japanese (2.0%) [38], and American (3.4%) [39] populations.

2.3. The Prevalence of Childhood Abuse in Women with BPD

In the overall sample of 150 women, 136 participants reported childhood sexual, emotional, and physical abuse. Childhood emotional abuse was the most common form of abuse experienced (n = 126, 92.6%), followed by childhood sexual (n = 55, 40.4%) and physical abuse (n = 48, 35.3%).

2.4. The Prevalence of PCOS and Fibromyalgia Diagnoses Categories of Abuse

The category of childhood abuse, both exclusive and concomitant, as well as the prevalence of PCOS and fibromyalgia in each sub-category, are represented in Table 2. The highest proportion of PCOS diagnoses was observed in the group who experienced emotional abuse exclusively (22.8%), and the highest proportion of fibromyalgia diagnoses was observed in the group who experienced physical, sexual, and emotional abuse concomitantly (12.5%).

2.5. Exploratory Analysis of the Additive Impact of Abuse Types

The small number of participants reporting experiences of sexual and physical abuse exclusively made it challenging to explore the second hypothesis comprehensively. Consequently, an exploratory analysis was conducted to determine whether exposure to emotional abuse is exclusively associated with an increased risk of developing PCOS and fibromyalgia or whether experiencing other forms of abuse in combination with emotional abuse increases the likelihood of a diagnosis of PCOS or fibromyalgia. As indicated in Table 2, of those participants who reported experiencing childhood emotional abuse exclusively, 22.8% had a diagnosis of PCOS, while 7% had a diagnosis of fibromyalgia. Moreover, of those participants who reported experiencing emotional abuse in combination with physical abuse and/or sexual abuse, 11.6% had a diagnosis of PCOS, while 10.1% had a diagnosis of fibromyalgia.

3. Discussion

The primary aim of this study was to investigate whether the prevalence rates of PCOS and fibromyalgia were higher in women with BPD compared to the general population. The second aim was to investigate whether the prevalence rates of PCOS and fibromyalgia were higher in women who reported experiencing childhood emotional abuse compared to those who reported experiencing childhood physical or sexual abuse. A further exploratory aim was to compare the prevalence rates of PCOS and fibromyalgia in women with BPD who experienced emotional abuse exclusively to those who experienced emotional abuse in addition to other forms of abuse.
As expected, the results revealed that both PCOS and fibromyalgia prevalence rates were substantially higher in women with BPD compared to the general population [34,35,36]. The results are consistent with previous research that found an association between BPD and PCOS [9].
Additionally, while no prior research has examined fibromyalgia prevalence rates within a BPD sample, our findings are consistent with several studies that have examined BPD prevalence rates within fibromyalgia samples, with prevalence rates ranging from 16.7% to 30% [18,41]. The high prevalence of comorbid fibromyalgia and BPD observed in this study may be explained by the self-regulation difficulties experienced by patients with BPD as it has previously been suggested that patients with BPD may have difficulties in regulating the experience of pain [42,43].
The proportion of PCOS diagnoses in the sample was 11.1% and 22.8% for participants who experienced only sexual and only emotional abuse, respectively. The large discrepancy between these proportions, with a substantially larger value being observed in those participants who experienced emotional abuse exclusively, tentatively supports the second hypothesis. However, it should be noted that the sample size of participants who reported experiencing sexual abuse exclusively was small (n = 9). Given that only one participant reported the experience of physical abuse exclusively, no commentary can be made on the difference in PCOS prevalence rates between those who exclusively experienced emotional or physical abuse.
Results from the final exploratory analysis indicated that a higher proportion of PCOS diagnoses were observed in those women who had experienced emotional abuse exclusively (13/57; 22.8%), relative to those who had experienced emotional abuse in addition to other forms of abuse (8/69; 11.6%). Firstly, this suggests that the additive experiences of sexual and/or physical abuse in combination with emotional abuse do not increase the risk of developing PCOS in women with BPD. The results of this study contradict the findings of most prior research, which indicates that exposure to multiple forms of abuse compared to single forms of abuse increases the likelihood of experiencing adverse health outcomes [44,45]. Thus, it is possible that the increased proportion of PCOS diagnoses in the group who experienced emotional abuse exclusively could be explained by an imbalance in confounding characteristics between groups, including possible factors that relate to the abuse experience (i.e., timing and chronicity of abuse).
The results also revealed that 7% (4/57) of participants who reported experiencing childhood emotional abuse exclusively had a diagnosis of fibromyalgia, while no fibromyalgia diagnoses were observed in participants who reported experiencing childhood sexual abuse exclusively (0/9). The relatively large discrepancy in fibromyalgia prevalence rates in participants who experienced sexual or emotional abuse exclusively tentatively supports the hypothesis that fibromyalgia prevalence rates are higher in those who experienced emotional abuse exclusively compared to those who experienced sexual abuse exclusively. As there was a limited number of participants reporting an experience of sexual (n = 9) and physical abuse (n = 1), these findings should be treated with caution. The tentative findings that fibromyalgia prevalence rates are higher in those who experienced childhood emotional abuse exclusively compared to those who experienced sexual abuse exclusively are consistent with most prior research [46,47].
The role that childhood emotional abuse appears to play in increasing the likelihood of the development of fibromyalgia may be explained by the possibility that emotionally abusive events elevate the perception of symptoms as being uncontrollable [48]. Illness uncertainty has been associated with difficulties in coping with fibromyalgia symptoms, ultimately making these individuals more vulnerable to pain [49]. Thus, emotional abuse may be indirectly associated with poorer symptom-coping abilities and, consequently, elevated pain levels.
Furthermore, the results of the exploratory analysis revealed that the highest prevalence of fibromyalgia diagnoses was observed in those participants who experienced emotional abuse in combination with other forms of abuse (7/69; 10.1%) compared to those who experienced emotional abuse exclusively (4/57; 7.0%). These results suggest that the additive experiences of physical and sexual abuse alongside the experience of emotional abuse increase the risk of developing fibromyalgia in women with BPD. Consequently, they are more likely to be exposed to chronic stress, leading to sustained disruptions to the HPA axis [50,51]. Thus, the findings of this study are congruent with recent research, which indicates that individuals who have been exposed to multiple types of abuse are more likely to report adverse health outcomes [44,45].

Limitations and Implications

One of the limitations of the current study in comparing prevalence rates of PCOS and fibromyalgia diagnoses in women with BPD to the general population was the lack of a control group. Consequently, we were unable to conduct a precise comparison of fibromyalgia and PCOS prevalence rates between participants with BPD and a control group from a sample with similar characteristics. Additionally, while the total sample size in the current study is relatively large, the sample sizes in the physical and sexual abuse categories were exclusively limited. Thus, we were unable to make explicit commentary on the link between sexual or physical abuse and disease prevalence rates.
While some prior research has examined the prevalence of physical health disorders [9] in individuals with BPD, to the researcher’s knowledge, no prior research has examined the prevalence rates of PCOS and fibromyalgia in this population. The findings of this study suggest that a tentative link may exist between BPD and the development of PCOS and fibromyalgia. By identifying that the prevalence rates of PCOS and fibromyalgia are substantially higher in women with BPD compared to the general female population, results from this study could establish the foundations for developing protocols to screen women with BPD for the presence of these physical disorders.
The broader implications of identifying these links are substantial. Medically, the combination of these chronic conditions can lead to significant physical health burdens, including infertility, chronic pain, and increased cardiovascular risks. Socially, these disorders may disrupt relationships and employment, increasing reliance on family and social support. Economically, the healthcare costs and potential loss of income further strain individuals, families, and the healthcare system. Therefore, acknowledging and addressing the intersection of these conditions early could mitigate the personal and societal burden.
By identifying specific abuse profiles that appear to increase the likelihood of developing PCOS and fibromyalgia in women with BPD, clinicians may be better able to identify the subset of women with BPD who are most at risk of developing these physical health disorders later in life. Furthermore, the findings of this study could establish the foundations for developing effective early-life screening, prevention, and intervention programs to reduce both the healthcare and personal burden associated with the enduring physical effects of certain forms of childhood abuse. Given the critical and significant medical and psychological consequences of PCOS and fibromyalgia, future research should endeavour to further establish the prevalence rates of PCOS and fibromyalgia in those who have survived childhood abuse, employing larger sample sizes to ensure sufficient comparisons between abuse categories.

4. Materials and Methods

4.1. Participants

Participants were identified from the MAPrc WMHC database. The WMHC is a second opinion service that provides psychiatric consultation for women with several mental health disorders, including BPD. Women who attended the WMHC at MAPrc from January 2017 to May 2021 were included if they (1) had a clinical diagnosis of BPD, (2) had a current diagnosis of PCOS and/or fibromyalgia, and (3) had previously completed the WMHC database Participant Consent Form. Ethical approval was obtained from the Alfred Hospital Ethics Committee, Melbourne, Australia on 1 September 2017.

4.2. Procedure

To investigate the first aim, the WMHC database was searched from 2017 to May 2021, and women who self-reported a diagnosis of BPD were identified. Of these women, those with a diagnosis of PCOS and/or fibromyalgia were identified.
To address the second aim, women with a diagnosis of BPD who experienced abuse, specifically childhood sexual, emotional, or physical abuse, before the age of 18, were identified. Women who experienced other forms of abuse, such as bullying or neglect, as well as those who did not experience childhood abuse, were excluded. Furthermore, women who reported that they had experienced childhood abuse but did not specify the type of abuse were also excluded.
Information regarding medical history (including PCOS and fibromyalgia) and abuse history were collected via forms and questionnaires formulated by the authors (J.K).

4.3. Statistical Analysis

All data were analysed using IBM SPSS Statistics Version 28.0. The mean and standard deviation of age were generated to characterise the sample.
The proportion of participants with a diagnosis of PCOS and/or fibromyalgia within the present sample was determined by dividing the number of reported diagnoses of PCOS or fibromyalgia by the total sample size. The PCOS prevalence rates in two Australian studies [34,35] and one Spanish [36], and the fibromyalgia prevalence rates in a Swedish [37], Japanese [38], and American [39] study were sourced to provide an indication of disorder prevalence rates in the general population, to which the proportions observed in the current study could be compared.
The frequency counts and proportions of women with BPD who experienced each different type of childhood abuse (physical, sexual, or emotional) were determined by encompassing all women who had experienced a specific type of abuse, including those who had experienced that type of abuse exclusively (unique experiences of abuse) and those who had experienced that type of abuse in addition to other forms of abuse (co-occurring forms of abuse). The frequency counts, and proportions of PCOS and fibromyalgia diagnoses within each of the seven unique categories of abuse experiences (emotional, physical or sexual, emotional and sexual, emotional and physical, physical and sexual, and all three forms of abuse) were also calculated.
Given the limited number of participants reporting exclusive experiences of childhood sexual or physical abuse, the overlapping and co-occurring nature of childhood abuse experiences in the current sample and the large proportion of participants reporting exposure to childhood emotional abuse, descriptive rather than inferential statistics were utilised.
Finally, an exploratory analysis was conducted to determine whether the exposure to childhood physical and sexual abuse alongside emotional abuse had an additive impact on the risk of developing PCOS and fibromyalgia compared to being exposed only to emotional abuse. Frequency counts, and proportions of PCOS and fibromyalgia diagnoses in participants who had experienced emotional abuse exclusively and who had experienced emotional abuse in addition to sexual and/or physical abuse, were calculated.

Sample Size Calculation

A sample size calculation was conducted using G*Power 3.1.9.7 software. The calculation was based on detecting an effect size of 0.23, which was determined from previous studies on the prevalence of PCOS and fibromyalgia in women with BPD [34,35]. With an alpha level of 0.05 and a power of 0.80, the analysis indicated that a minimum of 148 participants would be necessary to detect a statistically significant difference.

5. Conclusions

In conclusion, our study reveals that women with BPD have significantly higher prevalence rates of PCOS and fibromyalgia compared to the general population, with emotional abuse during childhood emerging as a potential risk factor, particularly when it occurs without concurrent physical or sexual abuse. Additionally, the combination of emotional, physical, and sexual abuse may further increase the risk of fibromyalgia. While limitations such as the lack of a control group and small sample sizes in certain abuse categories should be noted, these findings underscore the importance of screening for these conditions in women with BPD, especially those with a history of emotional abuse. Future research should confirm these associations with larger samples and explore underlying mechanisms, ultimately guiding the development of targeted screening, prevention, and intervention strategies to mitigate the long-term health effects of childhood abuse in this population.

Author Contributions

T.T. reviewed the WMHC database to identify eligible participants for the study, performed the statistical analyses, and drafted the manuscript. J.K. and E.M. developed the theoretical framework and supervised the project. All authors interpreted the results and provided critical revisions to the manuscript. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

This study was approved by the Alfred Hospital Ethics Committee (AH 285/17) on 1 September 2017.

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors on request.

Acknowledgments

We thank the women for participating in this research.

Conflicts of Interest

The authors declare no conflicts of interest.

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Table 1. Female prevalence rates (%) of PCOS and fibromyalgia in the general population compared to the BPD population in the present study (n = 150).
Table 1. Female prevalence rates (%) of PCOS and fibromyalgia in the general population compared to the BPD population in the present study (n = 150).
StudyYearCountryPopulationSample SizePrevalence of PCOS % Prevalence of
Fibromyalgia % 		Prevalence of
Participants with PCOS and Fibromyalgia %		Mean Age (Min–Max) a
Avery, Moran [34]2019AustraliaGeneral15275.6 47.4
(15–95)
March, Moore [35]2009AustraliaGeneral7288.7 b
11.9 c		 30.2
(27–34)
Asunción, Calvo [36]2000SpainGeneral1546.5 33.1 (18+)
Lindell, Bergman [37]2000SwedenGeneral2425 1.3 (20–74)
Toda [38]2007JapanGeneral343 2.0 38.6
(19–69)
Tsinanis et al.
(current study)		2024AustraliaBPD15017.38.72.039.0
(15–75)
Wolfe, Ross [39]1995USAGeneral3006 3.4 >18
a is the age range (the minimum to maximum age of participants in each study). b is the proportion of PCOS diagnoses in the sample based on the National Institutes of Health criteria [40] for diagnosing PCOS. c is the proportion of PCOS diagnoses in the sample based on the Rotterdam criteria [9] for diagnosing PCOS.
Table 2. Frequency count (n) and proportion (%) of PCOS and fibromyalgia diagnoses within each category of abuse in women with BPD (n = 136).
Table 2. Frequency count (n) and proportion (%) of PCOS and fibromyalgia diagnoses within each category of abuse in women with BPD (n = 136).
Abuse CategoryPCOS Diagnosis % (n)Fibromyalgia Diagnosis % (n)
Sexual (n = 9)11.1 (1)0 (0)
Physical (n = 1)0 (0)0 (0)
Emotional (n = 57)22.8 (13)7.0 (4)
Sexual and emotional (n = 22)9.1 (2)9.1 (3)
Physical and emotional (n = 23)17.4 (4)8.7 (2)
Physical and sexual (n = 0)N/AN/A
Physical, sexual, and emotional (n = 24)8.3 (2)12.5 (3)
Emotional abuse with concomitant physical and/or sexual abuse11.6 (8)10.1 (7)
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Mu, E.; Tsinanis, T.; de Boer, K.; Thomas, E.H.X.; Kulkarni, J. The Prevalence of Polycystic Ovary Syndrome and Fibromyalgia in Women with Borderline Personality Disorder and Their Association with Childhood Abuse. Women 2024, 4, 377-386. https://doi.org/10.3390/women4040029

AMA Style

Mu E, Tsinanis T, de Boer K, Thomas EHX, Kulkarni J. The Prevalence of Polycystic Ovary Syndrome and Fibromyalgia in Women with Borderline Personality Disorder and Their Association with Childhood Abuse. Women. 2024; 4(4):377-386. https://doi.org/10.3390/women4040029

Chicago/Turabian Style

Mu, Eveline, Tia Tsinanis, Kathleen de Boer, Elizabeth H. X. Thomas, and Jayashri Kulkarni. 2024. "The Prevalence of Polycystic Ovary Syndrome and Fibromyalgia in Women with Borderline Personality Disorder and Their Association with Childhood Abuse" Women 4, no. 4: 377-386. https://doi.org/10.3390/women4040029

APA Style

Mu, E., Tsinanis, T., de Boer, K., Thomas, E. H. X., & Kulkarni, J. (2024). The Prevalence of Polycystic Ovary Syndrome and Fibromyalgia in Women with Borderline Personality Disorder and Their Association with Childhood Abuse. Women, 4(4), 377-386. https://doi.org/10.3390/women4040029

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