BACKGROUND: The association between bipolar affective disorder (BAD) and polycystic ovarian syndrome (PCOS) is elucidated in medical literature. However, what is inconclusive is whether one causes the other and /or the neuroleptics such as sodium valproate could cause PCOS as a side effect. However, to the best of our knowledge, there is a dearth of such case reports in our setting. We therefore report a case of this nature in our setting with the aim of further reemphasizing the likely comorbidity and the need for collaborative multidisciplinary approach during management of such patients. CASE REPORT: We present a case of 34 years old, parity 0+1, human immune virus seronegative, a known patient of bipolar affective disorder (BAD) for 18 years. She was initially started on chlorpromazine and carbamazepine that she used for 13 years and later switched to sodium valproate and sertraline daily due to side effects of chlorpromazine in 2014. She presented with 6 years history of abnormal uterine bleeding and dysmennorrhoea for 2 months. A diagnosis of PCOS was made based on history and confirmed by laboratory and radiological investigations. CONCLUSIONS: Physicians need be aware of the likely comorbidity or sequel and the need for multidisciplinary engagement.

1. Polycystic Ovarian Syndrome Diagnosis in a Patient Undergoing Treatment for Bipolar Affective Disorder at Mbale Regional Referral Hospital, Uganda: A Case Report
IJGOR
Polycystic Ovarian Syndrome Diagnosis in a Patient Undergoing
Treatment for Bipolar Affective Disorder at Mbale Regional Referral
Hospital, Uganda: A Case Report
Achipa Doreen1, Nteziyaremye Julius*1,2
1Department of Obstetrics and Gynaecology, Faculty of Health Sciences, Busitema University, Uganda
2Department of Obstetrics and Gynaecology, Mbale Regional Referral Hospital, Uganda
BACKGROUND: The association between bipolar affective disorder (BAD) and polycystic ovarian
syndrome (PCOS) is elucidated in medical literature. However, what is inconclusive is whether
one causes the other and /or the neuroleptics such as sodium valproate could cause PCOS as a
side effect. However, to the best of our knowledge, there is a dearth of such case reports in our
setting. We therefore report a case of this nature in our setting with the aim of further
reemphasizing the likely comorbidity and the need for collaborative multidisciplinary approach
during management of such patients. CASE REPORT: We present a case of 34 years old, parity
0+1, human immune virus seronegative, a known patient of bipolar affective disorder (BAD) for
18 years. She was initially started on chlorpromazine and carbamazepine that she used for 13
years and later switched to sodium valproate and sertraline daily due to side effects of
chlorpromazine in 2014. She presented with 6 years history of abnormal uterine bleeding and
dysmennorrhoea for 2 months. A diagnosis of PCOS was made based on history and confirmed
by laboratory and radiological investigations. CONCLUSIONS: Physicians need be aware of the
likely comorbidity or sequel and the need for multidisciplinary engagement.
Key words: Bipolar affective disorder; polycystic ovarian syndrome; sertraline; sodium Valproate; Mbale; Uganda.
INTRODUCTION
Polycystic ovary syndrome (PCOS) also known as Stein
and Leventhal syndrome, is the most common endocrine
disorder in reproductive aged women, with a prevalence
estimated to be between 5% and 15%, depending on the
diagnostic criteria one uses (DA., 2005; Lauritsen MP,
2014). It was first described by Stein and Leventhal as a
syndrome of oligoamenorrhoea and polycystic ovaries,
additional clinical signs such as hirsutism, acne, and
obesity have continued to define the syndrome (Barbieri
RL, 1983; Irving F. Stein, 1935).
Since the 1990 National Institutes of Health-sponsored
conference on polycystic ovary syndrome (PCOS), it has
become appreciated that PCOS is a syndrome rather than
a single clinical entity and thus encompasses an array of
signs and symptoms. The 2003 Rotterdam consensus
workshop concluded that PCOS is a syndrome that may
include menstrual irregularities, signs of androgen excess,
and obesity. Moreover, according to the Rotterdam
criteria, diagnosis of PCOS requires the presence of at
least two of the following three findings:
hyperandrogenism, ovulatory dysfunction, and polycystic
ovaries (Group, 2004). Therefore, clinically diagnosing a
woman as having PCOS implies an increased risk for
infertility, dysfunctional uterine bleeding, endometrial
carcinoma, obesity, type 2 diabetes mellitus (DM),
dyslipidaemia, hypertension, and possibly cardiovascular
disease (CVD)- all that have wide implications both
economically and socially (Ricardo Azziz, 2009 ).
The relationship between mental disorders and PCOS par
se is not a straightforward one. Symptoms that are
associated with the syndrome itself such as acne,
hirsutism, scalp hair loss, menstrual disorders with
infertility and obesity are normally distressing enough and
have been associated with impaired quality of life.
*Corresponding Author: Nteziyaremye Julius,
Department of Obstetrics and Gynaecology, Faculty of
Health Sciences, Busitema University, Uganda.
Email: jntezi@gmail.com
Research Article
Vol. 5(1), pp. 047-052, August, 2020. © www.premierpublishers.org. ISSN: 1407-8019
International Journal of Gynaecology and Obstetrics Research

2. Polycystic Ovarian Syndrome Diagnosis in a Patient Undergoing Treatment for Bipolar Affective Disorder at Mbale Regional Referral Hospital, Uganda: A Case Report
Achipa and Nteziyaremye 48
Moreover, several studies (Aaron et al 2016, Gökhan
Açma et al. 2013, Mallon et al. 1999, Sonino et al. 1993;
Susanne et al. 2012) have demonstrated need for the
physicians to put into consideration emotional assessment
in patients diagnosed with PCOS. (Aaron J. Dawes, 2016;
Gökhan Açmaz, 2013; Mallon E, 1999 ; N. Sonino, 1993;
Susanne M. Veltman-Verhulst, 2012). Further still,
pharmacological agents used to manage mental disorders
have also been implicated as predisposing factors to
PCOS (McIntyre RS, 2003; O'Donovan C, 2002; Okanović
M, 2016 ; Rasgon NL, 2005).
Case presentation: We present a case of 34 years old,
parity 0+1, seronegative for Human Immune Virus (HIV),
laboratory assistant by profession who presented to
Gynaecology outpatient clinic of Mbale regional referral
hospital in Eastern Uganda, East Africa in October 2019
with 6years history of abnormal uterine bleeding and
dysmennorrhoea for 2 months 4years history of
intermenstrual bleeding and Painful menstrual periods for
2 months.
History of presenting complaints
She had generally been well till about 16 years prior to the
date of presentation. Her initial symptoms were those of
elated mood with associated flight of ideas. She was
brought to our Psychiatry department and a diagnosis of
bipolar affective disorder (BAD) was made. She was
consequently started on Chlorpromazine (she could not
remember the dose) and 400mg of carbamazepine
(400mg). She reports to have been on and off these drugs
till 2014 when she was switched to sodium valproate (1 gm
per day) and 200mg of oral sertraline daily.
Chlorpromazine was reportedly stopped because of
tardive dyskinesis.
She reportedly had had no complaints about her menses
till about, 6 years prior to the date of review. She had her
menarche at 11 years of age, cycles had initially been
regular with 4 days of menses till 2008.In 2008 she had
periods only once but later normalized till 2013.She
noticed that her periods had become irregular particularly
from August 2013 to February 2016.She reported
episodes of oligoamenorrhoea and abnormal uterine
bleeding characterized by menorrhagia and
dysmennorrhoea.
However, between March 2016 and September 2018, she
had amenorrhoea for which she sought treatment from a
private facility and was started on combined oral
contraceptives (COCS) for 5months. Her periods
reportedly normalized for six months but later became
amenorrhoeic for 5 months prior to review.
In 2014 she was surgically treated for incomplete abortion
at about 3 months of gestation. She reported history of
seeking treatment for infertility with no success in 2016.
There was no history of assisted reproductive therapy.
She reported that over the 10 years period, she had gained
excess weight, especially over her belly and trunk but no
history suggestive of hyperprolactinaemia or thyroid
disease. Family and social history were unremarkable.
Examination
She was in a fair general condition, well kept, looked
overweight but had no features suggestive of
androgenism.
Weight 86kg, Height =165cm
Body Mass Index (BMI) = 86/(1.65)2 Kg/m2 =31.62 Kg/m2
(Obesity) with a pannus especially central Obesity and a
waist circumference of 91cm.
System examinations: revealed normal findings.
INVESTIGATIONS AND RESULTS
 Transvaginal ultrasound scan October
o The ovaries are enlarged and have more than 12
follicles each measuring up to 6mm in diameter
o Right ovary = 13.2cm3
o Left ovary = 26.09cm3
o The uterus appeared normal
o Endometrium = 8mm thick
o No mass seen in the pelvis
 Small cysts on the cervix (5mm) noted.
 Urinalysis: Leukocytes = trace, Protein = Nil, Glucose
= Nil, Pus cells +, Microscopy: Motile rods noted
Random blood sugar = 3.9 mmol/l
Table 1: Hormonal assays done
Hormone Value
Luteinizing Hormone 24.5 IU/L
Follicle Stimulating Hormone(FSH)= 2.0 IU/L
Estradiol 24.49pg/ml
LH: FSH=12.25
Note: Biochemical hyperandrogenism test was not done
because these are out-of pocket services and client could
not afford.
Diagnosis: P0+1, Known patient of BAD on treatment
with Polycystic Ovarian Syndrome (PCOS)?
Endometrial hyperplasia and Urinary tract infection
Treatment: She was managed on tablets of Metformin
500mg once a day, Tabs MEFTAL – ASPAS (Mefanamic
acid 250mg+Dicyclomine 10mg) 500mg 8hrly, Caps
progesterone 400mg once a day for 10days. Tabs
cefuroxime 500mg 12hrly for 5 days and supportive
management that included scheduled exercise (aerobics)
and avoiding sedentary lifestyle. We subsequently
engaged the nutrition unit to provide the diet lessons and
continued management with colleagues in psychiatry.

3. Polycystic Ovarian Syndrome Diagnosis in a Patient Undergoing Treatment for Bipolar Affective Disorder at Mbale Regional Referral Hospital, Uganda: A Case Report
Int. J. Gynecol. Obstet. Res. 49
DISCUSSION
According to Androgen Excess Polycystic Ovarian
Syndrome Society Task Force (AE-PCOS-S TF),
Polycystic Ovarian Syndrome (PCOS), also known as
Stein and Leventhal syndrome, should be defined by the
presence of hyperandrogenism (clinical and/or
biochemical), ovarian dysfunction (oligo-anovulation
and/or polycystic ovaries), and the exclusion of related
disorders. It is the most common endocrine disorder in
reproductive aged women, with a prevalence estimated to
be between 5% and 15%, depending on the diagnostic
criteria applied (DA., 2005; Lauritsen MP, 2014).First
described by Stein and Leventhal as a syndrome of
oligoamenorrhoea and polycystic ovaries, additional
clinical signs such as hirsutism, acne, and obesity have
continued to define the syndrome(Barbieri RL, 1983; Irving
F. Stein, 1935). However, according to Ricardo et al,2009,
there may be forms of PCOS without overt evidence of
hyperandrogenism(Ricardo Azziz, 2009 ).In our case we
were not able to demonstrate evidence of biochemical
hyperandrogenism because of financial constraints.
Although the pathogenesis of PCOS remains elusive,
there is an accepted view that it seems to arise as a
complex trait that results from the interaction of diverse
genetic and environmental factors that usually first
become evident at puberty. Moreover, according to
Ehrmann et al 2016,PCOS can be understood through a
two-hit hypothesis-the first being a congenitally
programmed predisposition and the second hit hypothesis
being due to exposure to environmental stimulants
(Ehrmann, 2016). Vink et al ,2006, in their study further
pointed to the familial and genetic factors to PCOS with
resemblance in monozygotic twin sisters compared to
dizygotic twins as evidenced by tetrachoric correlation and
trivariate genetic analysis of oligoamenorrhoea ,acne and
hirsutism confirmed familial component(J. M. Vink, 2006).
However the pathogenesis of PCOS has been linked to
altered luteinizing hormone (LH) action, insulin resistance,
and possibly hyperandrogenism (A J Jakimiuk 2001;
Konstantinos Dafopoulos 1, 2009 ; Seija Korhonen, 2001).
According to Catherine Marin DeUgarte et al, 2005,the
underlying insulin resistance up regulates
hyperandrogenism by suppressing synthesis of sex
hormone–binding globulin (SHBG) and increasing adrenal
and ovarian synthesis of androgens, thereby increasing
androgen levels, which eventually lead to irregular menses
and physical manifestations of hyperandrogenism
(Catherine Marin DeUgarte, 2005)
Furthermore, relationship between PCOS and BAD either
as a comorbidity or sequel has been elucidated. Whereas
endocrine disturbances could account for distressing
symptoms and signs of PCOS and thus predispose one to
BAD, Richard et al ,1998,demonstrated that nearly 50%
of sisters of women with PCOS are hyperandrogenism
(Richard S. Legro, 1998), while Liu et al, 2014,showed that
brothers of such women also had alterations in
gonadotropin and steroidogenic hormone secretion (D.M.
Liu, 2014).These two studies suggest that PCOS has a
genetic predisposition. Furthermore, shared familial
factors between PCOS and psychiatric disorders may
exist, including a common genetic predisposition, as well
as shared psychosocial factors in childhood.
PCOS’ relationship with psychiatric disorders seems to
begin at the maternal-fetal interface and even beyond.
Children of mothers that suffer from PCOS are also at risk
of psychiatric disorders. Thomas et al ,2018, in their study
further emphasized the hit1 and hit 2 hypotheses of PCOS
as put forth by Carolyn et al ,2016 ,and Ehrmann et al,
2016.(Carolyn E Cesta, 2016; Ehrmann, 2016)
Hum et al,2015 demonstrated that maternal androgen
excess are thought to predispose to anxiety in the children
of mothers with PCOS as demonstrated in a study
involving rodent models in whom prenatal androgen
exposure resulted in increased anxiety-like behavior in
offspring, mediated via androgen receptor activation in the
amygdala and accompanied by changes in serotonergic
and beta-aminobutyric acid genes in the amygdala and
hippocampus (Hu M, 2015) .Brain development is
influenced significantly by exposure to androgens during
early gestation. Female rhesus monkeys exposed in utero
to androgens show increased male-type behavior(Hines,
2008) whereas both attention deficit hyperactive disorder(
ADHD) and autism spectrum disorder (ASD) are more
likely to be diagnosed in males than females(Baron-
Cohen, 2011; Rucklidge, 2010)
That notwithstanding, a study in Iowa by Kerchner et al,
2009 showed that those diagnosed with major
depressive disorder and other depressive syndromes,
anxiety syndromes, and binge eating disorder, PCOS was
a significant risk in this population. (Kerchner A, 2009).
Moreover Jeng-Hsiu Hung et al, 2014, in Taiwan, Fatemeh
et al,2013 in Vali e asr hospital and Arshad et al ,2015 in
Kashmir underpin a significant relationship between
psychiatry disorders(including but not limited to BAD) and
PCOS (Fatemeh Davari-Tanha, 2013; Jeng-Hsiu Hung
2014). In this case although efforts were made to inquire
about the other family members, no one seemed to have
the psychiatric or reproductive problems. It is possible that
the patient did not have a full history about all the family
members.
Moreover, associations between BAD pharmacological
agents and PCOS have been noted. Isojärvi et al,1993,
reported the association of sodium valproate and PCOS(J I
Isojärvi 1, 1993) and In vitro studies demonstrated that
valproate stimulated androgen biosynthesis in human theca
cells at doses that represented therapeutic levels in the
treatment of epilepsy or bipolar disorder by increased levels
of dehydroepiandrosterone (DHEA), androstenedione, and
17α-OH-progesterone, and decreased levels of
progesterone (Velen L Nelson-DeGrave 2004).
Furthermore, McIntyre et al ,2003, the patients with bipolar

4. Polycystic Ovarian Syndrome Diagnosis in a Patient Undergoing Treatment for Bipolar Affective Disorder at Mbale Regional Referral Hospital, Uganda: A Case Report
Achipa and Nteziyaremye 50
affective disorders treated with sodium valproate were
more likely to be obese with higher leptin levels, have
menstrual irregularities ,raised follicular phase androgen
concentrations compared to those managed with Lithium
(McIntyre RS, 2003).These findings have been
emphasized by other researches that have concluded that
sodium valproate may also increase the risk of menstrual
disorders, infertility and other associated symptoms of
polycystic ovarian syndrome(O'Donovan C, 2002; Okanović
M, 2016 ). Rasgon et al, 2005, in their study they found
higher rates of menstrual disturbances in women with
bipolar disorder and these in most cases, preceded its
diagnosis and treatment. They thus concluded that
valproate may contribute an additional risk rather than the
mere cause (Rasgon NL, 2005).Furthermore, another study
showed new-onset PCOS features (oligoamenorrhoea and
hyperandrogenism) developed in 10% of women taking
valproate within one year of its initiation, compared to 1% of
non-valproate users(Hadine Joffe 2006 ). In another study,
Morrell et al,2008, demonstrated that PCOS was likely to
develop in those in whom valproate was started in a young
population(below 40yrs of age)(Martha J Morrell 2008 ).
This patient was on sodium valproate 5 years prior to onset
of the PCOS symptoms. However, it must be made clear
that although sodium valproate increases the risk of PCOS
as has been reported in the above studies, this case cannot
be used to report it as a cause. Moreover, the prevalence of
PCOS in women with BAD, independent of psychotropic
treatments was similar to that seen in the general population
(Hadine Joffe 2006 ).This notwithstanding, studies by Bilo
et al ,1988, and Bauer et al,2000, did not demonstrate
association between valproate and PCOS(J Bauer 2000; L
Bilo 1988). This patient started neuroleptics before 40yrs of
age, and had never been married.
CONCLUSION
This single case cannot be used to conclude that BAD or
pharmacological management of it, predisposes to PCOS.
It is however, plausible that women with bipolar disorder
may also have neuroendocrine dysregulation because of
the psychiatric illness, which increases their susceptibility
to developing PCOS in the context of other potential risk
factors. Moreover, from the literature, it is paramount that
for patients presenting with features of PCOS or BAD,
family and social history are important in addition to
pharmacotherapy history. Attending physicians should
further look out for and or consult colleagues in order to
rule out coexistence or likely manifestation of the other at
a later time during follow up. Obstetrics and Gynaecology
physicians in Uganda should be aware of the various
metabolic and psychiatric disorders that could affect
patients diagnosed with PCOS. Therefore, referral to or
management of PCOS clients in consultation with
psychiatry physician and or clinical psychologist and a
dietician should be prioritized.
ABBREVIATIONS
ADHD - attention deficit hyperactive disorder
ASD - autism spectrum disorder
BAD - bipolar affective disorder
CVS - cardiovascular system
DM - diabetes mellitus
LH - luteinizing hormone
PCOS - polycystic ovarian syndrome
SHBG - sex hormone–binding globulin
DATA AVAILABILITY
Data sharing is not applicable to this article as no datasets
were generated or analyzed for this case report.
Ethics approval and consent to participate
Informed consent was obtained from the patient included
in the study
Conflict of interest
We declare no conflict of interest.
Funding
There was no funding for this work.
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Accepted 7 August 2020
Citation: Achipa D, Nteziyaremye J (2020). Polycystic
Ovarian Syndrome Diagnosis in a Patient Undergoing
Treatment for Bipolar Affective Disorder at Mbale Regional
Referral Hospital, Uganda: A Case Report. International
Journal of Gynaecology and Obstetrics Research. 5(1):
047-052.
Copyright: © 2020: Achipa and Nteziyaremye. This is an
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