Anxiety Symptoms in Patients with Mayer-Rokitansky-Küster-Hauser Syndrome: A Cross-Sectional Study

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Anxiety Symptoms in Patients with Mayer-Rokitansky-Küster-Hauser Syndrome: A Cross-Sectional Study

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a rare congenital disorder characterized by the absence or underdevelopment of the uterus and the upper two-thirds of the vagina, affecting approximately 1 in 4,000 to 5,000 females. This condition leads to infertility and challenges in vaginal intercourse, imposing significant psychological burdens on patients. While existing literature highlights psychological impacts such as depression, body image disturbances, and doubts about femininity, anxiety symptoms in MRKH patients remain underexplored. This study aimed to evaluate the prevalence of anxiety symptoms in MRKH patients, compare them with healthy controls, and identify associated risk factors.

Study Design and Participants

The cross-sectional study included 141 MRKH patients and 178 age-matched healthy women recruited from the Physical Examination Center of Peking Union Medical College Hospital (PUMCH) between January and December 2018. Patients with pre-existing psychiatric disorders were excluded. Participants completed an online questionnaire assessing demographic characteristics, medical history, and psychological states. The MRKH group had a mean age of 25.8 ± 4.6 years, with an average post-diagnosis period of 7.7 ± 4.5 years. Among them, 65.2% had type 1 MRKH (isolated uterovaginal agenesis), while 34.8% had type 2 MRKH (with renal or skeletal abnormalities). Treatment histories included non-surgical vaginal dilation (47.5%), vaginoplasty (29.1%), and no treatment (23.4%).

Measurement Tools

The Generalized Anxiety Disorder 7-item scale (GAD-7) served as the primary tool for assessing anxiety symptoms. Scores categorize symptoms as minimal (0–4), mild (5–9), moderate (10–14), or severe (15–21), with a cutoff ≥10 indicating clinically significant anxiety. Additional assessments included:

  • Patient Health Questionnaire-9 (PHQ-9) for depressive symptoms (cutoff ≥10).
  • Eysenck Personality Questionnaire-Revised, Short Scale for Chinese (EPQ-RSC) evaluating personality traits: extraversion, neuroticism, psychoticism, and social desirability (lie scale).
  • Chinese Version of the Female Sexual Function Index (CV-FSFI) to assess sexual function in sexually active patients (dysfunction defined as total score <23.45).
  • Custom questions addressing self-perceived femininity, family support, and reproductive plans.

Key Findings

Prevalence of Anxiety Symptoms

MRKH patients exhibited significantly higher anxiety levels than healthy controls. Using GAD-7, 24.1% (34/141) of patients reported moderate-to-severe anxiety symptoms (score ≥10), compared to 11.8% (21/178) in controls. The median GAD-7 score was 6.0 (interquartile range [IQR]: 3.5–9.0) for MRKH patients versus 5.0 (IQR: 1.0–7.0) for controls (P = 0.002). Severe anxiety (scores 15–21) affected 7.8% of patients, nearly triple the rate in controls (2.8%).

Associated Risk Factors

Univariable analysis identified several factors linked to anxiety in MRKH patients:

  1. Marital Status: Married patients had higher anxiety rates (40.0% vs. 19.8% in singles; P = 0.022).
  2. Self-Evaluation of Femininity: Negative perceptions of femininity were strongly associated with anxiety (40.0% vs. 15.4% in those with positive evaluations; P = 0.001).
  3. Depressive Symptoms: 54.2% of patients with depressive symptoms (PHQ-9 ≥10) had anxiety, compared to 8.6% without depression (P < 0.001).
  4. Sexual Dysfunction: Sexually active patients with dysfunction (CV-FSFI <23.45) reported higher anxiety rates (48.1%) than those with normal function (18.6%) or no sexual activity (18.3%; P = 0.002).
  5. Personality Traits: Neuroticism scores were significantly higher in anxious patients (68.7 ± 6.1 vs. 56.4 ± 11.4; P < 0.001), while extraversion scores were lower (44.5 ± 10.9 vs. 51.2 ± 10.9; P = 0.004).

Multivariable logistic regression confirmed three independent risk factors:

  • Negative Self-Evaluation of Femininity (OR = 2.706; 95% CI: 1.010–7.247; P = 0.048).
  • Coexisting Depressive Symptoms (OR = 4.422; 95% CI: 1.498–13.049; P = 0.007).
  • Neurotic Personality Traits (OR = 1.100 per unit increase; 95% CI: 1.029–1.175; P = 0.005).

Clinical and Psychological Implications

The study underscores the high prevalence of anxiety in MRKH patients, with nearly one-quarter experiencing moderate-to-severe symptoms. Negative self-perceptions of femininity emerged as a critical psychological stressor, likely exacerbated by societal pressures and internalized stigma. Neuroticism, characterized by emotional instability, amplified vulnerability to anxiety under the stress of diagnosis and treatment. The strong association between anxiety and depression highlights the need for comprehensive mental health screening in clinical settings.

Sexual dysfunction further compounded anxiety, emphasizing the importance of postoperative counseling and support. Despite surgical or non-surgical interventions to create a neovagina, nearly half of sexually active patients reported dysfunction, correlating with poorer mental health outcomes. This suggests that anatomical correction alone is insufficient without addressing psychological and relational well-being.

Limitations and Future Directions

The study’s cross-sectional design limits causal inferences. Longitudinal research could clarify whether anxiety precedes or results from MRKH-related challenges. Additionally, cultural factors specific to China, such as illegality of surrogacy and societal emphasis on biological motherhood, may influence findings. Generalizability to other populations requires caution.

Future interventions should prioritize cognitive-behavioral therapy (CBT) targeting negative self-schemas about femininity and infertility. Peer support networks and access to legal reproductive options (e.g., surrogacy where permitted) could mitigate anxiety. Routine integration of psychological assessments using GAD-7 and PHQ-9 in gynecologic care is recommended to identify high-risk patients.

Conclusion

This study provides robust evidence of elevated anxiety symptoms in MRKH patients, driven by neuroticism, depressive comorbidity, and negative self-perceptions. Clinicians must adopt a holistic approach, combining surgical treatment with mental health support to improve quality of life. Addressing cultural and legal barriers to alternative parenting options may further alleviate psychological distress in this population.

doi.org/10.1097/CM9.0000000000000648

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