Introduction
Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of reproductive age [1، 2]. Women with PCOS have a wide range of symptoms, including amenorrhea, oligomenorrhea, hirsutism, infertility, anovulation, weight gain or obesity, acne, androgenetic alopecia, and metabolic disorders [3، 4]. According to the Rotterdam criteria set by the European Society of Human Reproduction & Embryology and the American Society For Reproductive Medicine (ESHRE/ASRM), to diagnose PCOS after excluding other medical conditions leading to irregular menstrual cycle and hyperandrogenemia, at least two of the following three criteria should be met in the individual: oligomenorrhea or amenorrhea, hyperandrogenism, and the morphological appearance of polycystic ovaries (the presence of at least 12 or more small antral follicles in the ultrasound of the ovaries with a diameter between 2-9 mm or an increase in the size of the ovaries by more than 10 mm) [4‌-6]. 
According to the Rotterdam criteria, the global prevalence of PCOS is 5-10% [7] and its prevalence in Iran is relatively high (11.4%) [8]. The exact cause of PCOS is not clear, but the emergence of this syndrome is probably multifactorial and is caused by the interaction between genetic and environmental factors [8]. In reproductive age, the main complaint of patients is infertility and irregular ovulation [9]. This syndrome is the common cause of approximately 75% of infertility cases [10]. Patients with PCOS face an increased risk of uterine and ovarian cancer [11], late menopause [12], type 2 diabetes, high blood pressure, lipid disorders, cardiovascular disease [13، 14], depressed and anxious mood [15], Social phobia [16], eating disorders [17], suicide attempts [18] and bipolar disorder [19]. Studies show that the effects and complications left by PCOS cause psychological damage and a significant decrease in the quality of life (QOL) and health-related QOL in women with this syndrome compared to healthy women and even compared to those suffering from other diseases [20-24]. 
Factors affecting the QOL of women with PCOS in physical dimensions include overweight, hairiness, hair loss, acne lesions, menstrual disorders, and general health problems, and the factors in psychological, emotional, cognitive, and social dimensions include depression, despair, fear/anxiety, moodiness, introversion, low self-confidence, embarrassment/shame, impaired problem-solving and planning abilities, seclusion and isolationism, inability to express problems to those around, being blamed by the spouse for infertility, loss of femininity and the appearance of masculinity, disruption in marital relations, etc. [25‌، 26]. As a result, PCOS is a chronic disease that negatively affects both the physical and mental health of patients and their QOL [27]. This syndrome is not a disease specific to the reproductive age and adolescence. Due to its high prevalence, it can create a great health and economic burden on countries [28]. 
So far, different interventions have been developed to improve the QOL of women with PCOS [29-33], one of the most important of which is psychological interventions combined with medication therapy [34، 35]. Psychological interventions can change all aspects of life. Since women with PCOS are very prone to psychological disorders, psychological interventions can be useful [36-39]; however, to make a decision about their efficiency, a detailed investigation is needed. A scoping review study is used to critically evaluate and produce a conclusion for a particular question and to provide evidence. Unlike a systematic review, there is no need for complex statistical analyses such as meta-analysis in this type of review study. To our knowledge, a comprehensive review study has not been conducted in this field so far. A scoping review can be effective for systematic and interventional studies [40]. In this regard, and due to the great importance of QOL in women with PCOS, this scoping review study aimed to investigate psychological interventions for improving the QOL of women with PCOS.

Materials and Methods
This is a scoping review study, which was conducted in five stages according to the JBI approach. These steps are: 1- Identifying the research question, 2- Searching the related studies, 3- Selecting relevant studies, 4- Charting and summarizing the data, and 5- Reporting the results [40]. In the first step, the question was determined as: Are psychological interventions effective in improving the QOL of women with PCOS? The inclusion criteria were determined based on the PICO approach: Population (women with PCOS), Intervention (psychological interventions), Comparison (women with no psychological intervention), and Outcome (post-intervention QOL). For searching the related studies, the following keywords were used in Persian and English: “Psychological interventions”, “women”, “Quality of life”, and “polycystic ovary syndrome”. These keywords were used along the Boolean operators (AND, OR). The search was performed in Google Scholar, PubMed, EMBASE, Scopus, Cochrane Library, Science Direct, Web of Science, Scientific Information Database, IranDoc, IranMedex, and Magiran. All online articles published from 2010 to June 3, 2023 were searched. The reference list of identified articles was also manually searched to find more related studies. Searching was done independently by two researchers (first and second authors). The interventional studies (Quasi-experimental, experimental, and clinical trials), studies that investigated the effect of psychological interventions on the QOL of women with PCOS, those that met the PICO criteria, and those whose sample size and their results were clear were included in the study. The studies that did not meet the mentioned criteria and those with unavailable full texts were excluded.
The quality of articles was examined in terms of selection bias (random sequence generation and allocation concealment), implementation bias (blinding of participants and personnel), diagnosis bias (blinding of outcome assessor), sample missing (missing data after randomization), bias of selective outcome reporting, and other bias. In this regard, we used the risk of bias checklist provided by Cochrane Library (Table 1) [17]. Based on this tool, the quality of the articles was classified into three levels: “High”, “Low,” and “Unclear”.



The initial search yielded 901 articles. Three articles were also found by manual search. After removing duplicates, unrelated articles were identified by reading titles and abstracts. After removing unrelated articles, 30 remained. Fifteen studies were removed after reading their abstracts, and 4 were removed after reading their full texts. Finally, 11 articles were selected for the review (Table 2), and their information, including the name of the authors, year of publication, study area, study purpose, sample size, tool, study variables, study design, and results were extracted (Figure.1).








Results

Participants
Participants in all studies were women of reproductive age. There was a total of 477 participants. Their age range was from 15 to 47 years. Participants included women with PCOS having morbid obesity, adolescent women, those in the premenopausal period, and those with infertility [29-37].

Data classification
Reviewing the texts of 11 articles, the findings were divided into four groups based on the intervention used: cognitive behavioral therapy (CBT), motivational interview, mindfulness, and yoga. Six studies used CBT [32، 33، 35، 37-39], two studies used motivational interviewing [34، 36], two studies used yoga [29، 31], and one study used mindfulness [30] to improve the QOL in women with PCOS.

CBT
Of six studies used CBT, two studies applied relaxation, breathing techniques, problem-solving techniques, cognitive restructuring, managing negative thoughts, psycho-education about PCOS and its symptoms, anger control and talking about sexual issues in CBT sessions. CBT sessions were conducted by one expert with PhD in clinical psychology and one expert master in psychology [32، 33]. Their result showed improvement in the intervention group in both studies. Another study by Abdulahi investigated the effect of CBT in patients with PCOS [35]. In the CBT sessions, problem-solving techniques, anger control, and stress management skills were taught. After the intervention, the mean score of QOL in the intervention group significantly increased [35]. Another study by Majidzadeh et al. investigated the effect of CBT on QOL, depression and anxiety of women with PCOS [39]. The contents of the sessions were based on overcoming incompatible thoughts and changing them, reducing the use of painkillers, anti-anxiety and anti-depressants, and increasing daily activity (exercise) as well as anger control and stress management [39].

​Mindfulness therapy
One study investigated the effect of mindfulness intervention on the QOL of women with PCOS [30]. In this study, the effectiveness of Mindfulness-Based Stress Reduction (MBSR) therapy was evaluated in changing stress, anxiety, depression and QOL of women with PCOS. In the intervention sessions, mindfulness training, body scanning, breathing techniques, music and biofeedback support, group counseling and psycho-education (Psychological challenges, healthy habits including food and exercise, and mind-body interaction), stress and anxiety reduction, body image, and anger management were taught by a therapist expert in mindfulness therapy [30].

Yoga
In two studies used yoga [29، 31], the protocol included communication and interaction of participants with each other (30 minutes), muscle relaxation (10 minutes), yoga training with 5-10 breathing exercises (60 minutes), muscle relaxation with meditation and breathing techniques (10 minutes) and finally a question & answer session (10 minutes). Intervention sessions were conducted by a yoga instructor in both studies. The results of both studies showed satisfactory and effective role of yoga in improving the QOL of women with PCOS [29، 31].

Motivational interviewing
Two studies investigated the effect of motivational interviewing in improving the QOL of women with PCOS [34، 36]; one study conducted face-to-face [34] and one conducted virtually on WhatsApp [36]. Practicing and accurately identifying emotions, completing the impact of emotional dimensions, practicing brainstorming, the benefits of any short-term and long-term thinking, practicing completing the table of positive and negative dimensions, describing and practicing corrective and replacement options, defining values, defining the priority and importance of each person's values, defining a short-term and long-term plan, and discussing the prospects of these plans and their benefits were among the contents of motivational interviewing sessions. Both studies declared effective and satisfactory results.

Discussion
The current scoping review study evaluated 11 interventional studies that were conducted to investigate the effect of psychological interventions in improving the QOL of women with PCOS [29-37]. Six studies used CBT [32، 33، 35، 37-39], two studies used motivational interviewing [34، 36], two studies used yoga [29، 31], and one study used mindfulness [30] to improve the QOL of women with PCOS. All the studies reported the positive impact of psychological treatments in improving the QOL of women with PCOS and recommended their use along with another therapy (medication therapy, if necessary). The tool used in all 11 studies was PCOS questionnaire, which examines 5 domains (emotions, body hair, weight, infertility and menstrual problems).
In explaining the effectiveness of mindfulness therapy, it can be said that this therapy includes practicing the moment-by-moment awareness of thoughts, feelings and emotions in a non-judgmental manner [30]. This approach encourages women to consider distracting factors (such as negative and disturbing thoughts) as mental events, which are not necessarily accurate and true, and it is not necessary to believe in or pay attention to them [37]. There is evidence that the ability to include feelings in nonjudgmental words, which increases with mindfulness practice, is positively related to gray matter volume in the right anterior insula and right amygdala, indicating that the increase in this volume may reflect a person's greater awareness of the stressful situation and greater ability to cognitively manage emotions [42]. In the study that investigated the effect of mindfulness [30], two subscales of weight and body hair were significantly different after MBSR, but the other three subscales were not significant. To examine the impact on other dimensions, more use of mindfulness with a greater scope are needed, because the issues related to menstrual problems and infertility and emotions seem a little deeper [30].
In explaining the effectiveness of yoga on improving the QOL of women with PCOS, it can be said that this treatment has caused significant changes in all QOL aspects of women with PCOS (except infertility) by releasing negative thoughts and letting them go. In Nidhi et al.’s study, all areas were significant after yoga [29], but in Bahrami et al.'s study, all areas except infertility were declared significant [31]. This discrepancy can be attributed to the target population. In the first study, the samples were teenage women with PCOS [29], but in the second study, the samples were infertile women with PCOS [31]). The average scores after the intervention were also higher in Nidhi et al.’s study than in Bahrami et al.’s, which can also be due to the difference in the study samples. It seems that it is easier to intervene in adolescents without infertility. In cases with infertility, drug therapy is also needed. In other words, we cannot expect a statistically significant improvement in fertility simply by performing psychological methods.
In 2016 and 2018, Cooney et al. used CBT to improve the QOL of women with PCOS and reported its efficacy in all areas [32، 33]. They showed that CBT improved awareness, self-management, and mental state in women. In CBT, the therapist teaches the patient to answer stressful questions by using logical and current reasons [43]. Jalilian et al. showed significant changes in all areas of QOL after CBT compared to before the intervention, except for menstrual problems [38]. They recommended that CBT, along with drug therapy, can be very effective. Majidzadeh et al also confirmed the effectiveness of CBT in improving the QOL of women with PCOS [39]. Abdulahi et al. also reported that 8 sessions of CBT were effective in increasing the QOL score [35]. In Abdulahi et al.'s study, which was conducted on the age group of 18-35 years, CBT was more effective.
Another psychological treatment that was reported to have an impact on the QOL of women with PCOS was motivational interviewing. In two studies in Iran and Denmark in 2020 and 2018, motivational interviewing improved the QOL of women with PCOS [34، 36]. Ansari et al.'s study was conducted in Iran on infertile women with PCOS. Considering that infertility is one of the complications of PCOS, it may not necessarily occur in patients, but if occurs, it will certainly increase the psychological complications and effects on different aspects of life [44]. Thus, psychological interventions may be less effective for infertile women. However, Ansari et al. reported that the QOL of infertile women improved significantly after motivational interviewing [36]. In the study by Moeller et al., improvement in QOL after motivational interviewing was also reported [34]. However, in Moeller et al.’s [34] study, the effectiveness rate was higher, because the intervention was conducted face-to-face and weekly for 6 months, while in Ansari et al.'s study, the intervention was online at 5 sessions. Motivational interviewing provides a vision of the benefit of psychological changes in the long term by motivating patients, which can cause changes for recovery [45].

Conclusion
CBT, mindfulness therapy, motivational interviewing, and yoga training can be effective in improving the QOL of women with PCOS. However, there is scant research in this field. To access stronger evidence for the efficacy of psychological interventions in improving the QOL in PCOS women, more studies with less bias are needed.

Ethical Considerations

Compliance with ethical guidelines
This article is the result of a review study and did not have any human or animal samples.  Ethical issues such as avoiding plagiarism, ensuring robustness in collecting relevant data, and publishing rights were considered.

Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors' contributions
Initial draft preparation, data collection, search and investigation: Mahtab Haji Mohammadreza and Soghra Khani; Writing original draft: Mahtab Haji Mohammadreza , Soghra Khani and Zohre Shahhosseini; Editing and final approval: All authors.

Conflict of interest
The authors contributed equally to preparing this paper.


 

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