Advances in medical technology make it easier to detect disease earlier than ever. That’s a good thing when it means a deadly cancer can be caught promptly and stopped with treatment. But it isn’t so good for people who are labeled with a disease that has mild symptoms, if any, and only a low risk of getting worse. Such a diagnosis may do more harm than good, especially if the diagnosis adds an emotional burden and doesn’t change an individual’s treatment.
Take polycystic ovary syndrome, also known as PCOS, one of several overdiagnosed conditions we study. Symptoms of this hormonal and metabolic disorder include menstrual irregularities, not ovulating during a menstrual cycle, the presence of polycystic ovaries (enlarged ovaries that contain numerous small follicles that contain immature eggs) and signs such as acne and excess facial and body hair that the body is producing too much testosterone and other androgens. PCOS can be a cause of infertility and has been linked to the development of type 2 diabetes and potentially to cardiovascular disease.
In 2003, a meeting of experts in Rotterdam, Netherlands, expanded the criteria for diagnosing PCOS. That decision resulted in the inclusion of women with milder forms within the broadened spectrum of PCOS and contributed to a substantial increase in the number of women diagnosed with it. Estimates of this increase vary, and are influenced by factors such as ethnicity and the amount of obesity in the population. In a sample of Australian women, for example, the broadened criteria contributed to an estimated doubling of the number of women diagnosed with this condition, from around 9 percent to about 18 percent. However, not all women fitting the expanded criteria for the syndrome may be at risk for infertility, diabetes, or cardiovascular disease.
Symptoms suggestive of PCOS tend to emerge in adolescence. Making an accurate diagnosis during this life stage, however, is challenging because symptoms such as menstrual irregularity overlap with the normal signs of pubertal development. Just as important, there is no clear line dividing normal variability from the abnormality of PCOS, especially in young women. For instance, polycystic ovaries are often seen in women without PCOS. Symptoms can also change over the lifespan, vary in severity, and may be transitory for some women.
A few studies in different populations found that prevalence of the syndrome peaks between the ages of 20 to 25 years then rapidly decreases, suggesting that many women may “grow out of PCOS” by the time they are in their 30s.
The label of PCOS can have physical and emotional consequences for women. Wendy (not her real name) was 14 years old when her doctor said she had polycystic ovary syndrome. She was told she might have difficulty conceiving if she wanted to have children, and should lose 10 pounds — even though she was at a healthy weight — in order to preempt future weight gain. “It was quite a dramatic thing to tell someone so young that they may be infertile and to lose weight, which would have made me underweight,” says Wendy, now 24 years old.
For some women, a diagnosis of PCOS is appropriate and beneficial, such as among those with severe symptoms and those at increased risk of type 2 diabetes. For others, though, the potential impact of a diagnosis on psychological well-being should not be underestimated. As we wrote recently in the BMJ, we are concerned that women with mild PCOS symptoms or those at low risk of future illness may be getting a lifelong diagnosis that could do them more harm than good, inducing unnecessary fear and anxiety about future fertility and long-term health.
Women with PCOS have higher levels of depression and anxiety, poorer self-esteem, negative body image, disordered eating, and decreased sexual satisfaction. What we don’t know is whether these are solely due to the condition and its symptoms, or also stem from the psychological effects of being labeled as having PCOS.
Abigail was 28 when her general practitioner told her she had polycystic ovaries and may never be able to conceive. The diagnosis pressured Abigail and her partner to talk about having children at a time when they weren’t ready for it, which ultimately resulted in their separation. The diagnosis left Abigail feeling depressed and questioning her life choices. Later on, once she and her subsequent partner decided to have a family, she conceived straight away and now has two happy, healthy children. “I thought I was barren, never to have a child naturally. But the reality was, OK, I have this condition that might make conceiving tricky,” she said at age 45. “And when I fell pregnant the first time with my husband, I thought to myself, all those years of underlying background worry, eating away at me was a complete waste of time!”
All doctors are taught the maxim “First, do no harm.” However, there is an increasing body of evidence suggesting that overdiagnosis and giving people disease labels does cause harm and can fundamentally affect their well-being. The problem of widening disease definitions is a concern for many other conditions, such as osteoporosis, gestational diabetes, and hypertension, where people with lower risk of consequences receive permanent disease labels and lifelong treatments that might cause more harm than benefit.
We recently conducted a systematic review of how different terminologies used for the same condition can affect patients’ expectations. Although all identified studies were hypothetical, the results show that when clinicians use a more medical or precise label, people tend to want more invasive treatments, experience heightened anxiety, and perceive the condition as more severe. This suggests that when people are told they have a disease, they might start thinking of themselves as sick or abnormal, changing their behavior and sense of well-being.
Although the exact mechanisms for that remain unclear, disease labels have important implications. Health care providers need to make sure that there are solid grounds for, and clear benefits of, labeling a patient with a diagnosis before we start doing it more often.
Tessa Copp is a Ph.D. candidate in the School of Public Health at the University of Sydney, New South Wales, Australia. Kirsten McCaffery is a professorial research fellow and behavioral scientist in the School of Public Health at the University of Sydney. Jenny Doust is a general practitioner and professor of clinical epidemiology at Bond University, Queensland, Australia. Jolyn Hersch is an early career researcher in the School of Public Health at the University of Sydney. Jesse Jansen is a senior research fellow and cognitive psychologist in the School of Public Health at the University of Sydney.