Self-acceptance in patients with polycystic ovary syndrome: Associations with social anxiety and social support

Abstract

BACKGROUND

Polycystic ovary syndrome (PCOS) is associated with significant psychological distress, including anxiety and impaired self-perception. Self-acceptance is an important indicator of psychological well-being in patients with PCOS, yet the roles of social anxiety and social support in shaping self-acceptance remain insufficiently understood.

AIM

To examine the associations among social anxiety, perceived social support, and self-acceptance in patients with PCOS, to explore whether perceived social support represents a potential indirect pathway between social anxiety and self-acceptance, and to identify factors associated with self-acceptance.

METHODS

A cross-sectional study was conducted using convenience sampling. Patients with PCOS attending a gynecology outpatient clinic between April and December 2024 were recruited. Data were collected using a general information questionnaire, the Social Anxiety Subscale of the Self-Consciousness Scale, the Perceived Social Support Scale, and the Self-Acceptance Questionnaire. Pearson correlation analysis and multiple linear regression were performed. An exploratory mediation analysis was conducted using PROCESS Model 4. Given the cross-sectional design, the mediation model was interpreted as an indirect association rather than evidence of causal ordering.

RESULTS

A total of 366 patients were included. The mean social anxiety score was 18.86 ± 4.50, the mean social support score was 61.27 ± 13.17, and the mean self-acceptance score was 41.39 ± 7.30. Self-acceptance was positively correlated with social support (r = 0.429, P < 0.001) and negatively correlated with social anxiety (r = -0.598, P < 0.001). Social support was negatively correlated with social anxiety (r = -0.247, P < 0.001). Multiple linear regression identified ethnicity, number of appearance manifestations, social support, and social anxiety as independent factors associated with self-acceptance.

CONCLUSION

Self-acceptance in patients with PCOS was associated with both social anxiety and perceived social support. Perceived social support may represent one interpersonal pathway linking social anxiety with self-acceptance; however, causal direction cannot be established because of the cross-sectional design. These findings support the integration of psychological assessment and social support strategies into PCOS care.

Key Words: Polycystic ovary syndrome; Self-acceptance; Social anxiety; Social support; Psychological factors; Cross-sectional study

Core Tip: This study highlights the importance of psychological and social factors in patients with polycystic ovary syndrome (PCOS). We found that self-acceptance was negatively associated with social anxiety and positively associated with perceived social support. Exploratory mediation analysis suggested that perceived social support may partly explain the association between social anxiety and self-acceptance. Because this was a cross-sectional study, the findings should be interpreted as indirect associations rather than causal evidence. These results may help inform psychological assessment and supportive interventions for patients with PCOS.

INTRODUCTION

Polycystic ovary syndrome (PCOS) is the most common reproductive and endocrine disorder among women of reproductive age, affecting approximately 5%-18% of the female population worldwide. In addition to clinical manifestations such as oligomenorrhea, amenorrhea, infertility, hirsutism, acne, insulin resistance, and glucose-lipid metabolic disorders[1], PCOS is also associated with a range of psychological problems, including anxiety and depression[2]. These psychological disturbances significantly impair quality of life and contribute to long-term disease burden.

Despite advances in understanding the pathophysiology and management of PCOS, current therapeutic strategies remain limited. There is still a lack of targeted treatments addressing the underlying etiology, as well as reliable biomarkers for precise phenotyping and individualized management[2,3]. Furthermore, comprehensive long-term care models that integrate metabolic, reproductive, and psychological aspects are insufficiently developed[2,4,5]. As a result, psychological well-being remains an under-recognized yet critical component of PCOS management. The relationship between social anxiety, social support, and self-acceptance has not been thoroughly explored.

Self-acceptance is the ability of individuals to acknowledge and positively evaluate their own characteristics[6-8]. PCOS patients are prone to image problems due to physical changes such as hirsutism and acne, which can lower their self-esteem and self-acceptance levels, thereby exacerbating their psychological burden. Social anxiety is a high incidence psychological problem[9], induced by physical abnormalities and reproductive difficulties, which can reinforce self-denial and directly hinder self-acceptance.

Perceived social support may provide an important interpersonal pathway linking social anxiety with self-acceptance in patients with PCOS[10-13]. Social anxiety is commonly characterized by fear of negative evaluation, heightened interpersonal sensitivity, and avoidance of social situations[9,12]. In patients with PCOS, appearance-related manifestations, infertility concerns, and disease-related stigma may intensify worries about being judged or rejected by others[2,14]. Such anxiety may reduce patients’ willingness to disclose disease-related concerns, seek emotional support, participate in social interactions, or make effective use of available support[11,12]. As a result, patients with higher social anxiety may perceive less support from family members, friends, and significant others[12,13].

Perceived social support, in turn, may contribute to self-acceptance by providing emotional reassurance, external validation, illness-related understanding, and a sense of belonging[10-13]. Supportive relationships can help patients reinterpret disease-related changes, reduce feelings of shame and isolation, and maintain a more positive evaluation of the self[10,13,14]. Therefore, social support may partly explain the association between social anxiety and self-acceptance. However, this pathway should not be considered the only possible mechanism. Other factors, such as resilience, coping style, treatment experience, family relationships, and cognitive appraisal, may also contribute to self-acceptance[11,13].

Therefore, although previous studies have examined psychological distress, social support, and self-related outcomes in PCOS, the combined relationship among social anxiety, perceived social support, and self-acceptance remains insufficiently clarified. In particular, few studies have examined whether perceived social support represents a potential interpersonal pathway linking social anxiety with self-acceptance in patients with PCOS. Based on this rationale, we examined the associations among social anxiety, perceived social support, and self-acceptance, explored the indirect association between social anxiety and self-acceptance through perceived social support, and identified factors associated with self-acceptance. Given the cross-sectional design, the mediation analysis was considered exploratory and was not intended to establish causal direction.

MATERIALS AND METHODS

Study participants

A cross-sectional study was conducted using a convenience sampling method. Patients diagnosed with PCOS who attended the gynecology outpatient clinic of a university-affiliated hospital in Zhengzhou between April and December 2024 were recruited.

Inclusion criteria: (1) Diagnosis of PCOS in accordance with the Chinese Guidelines for the Diagnosis and Management of PCOS[15]; (2) Clear consciousness and ability to complete the questionnaire independently; and (3) No history of psychiatric disorders.

Exclusion criteria: (1) Comorbid endocrine disorders; (2) Experience of major stressful life events within the past two months; (3) Severe metabolic syndrome complications; and (4) Participation in other interventional clinical trials during the study period.

Sample size estimation was based on the principle that the sample size should be 5-10 times the number of variables. Considering that the Self-Acceptance Questionnaire (SAQ) includes 16 items, the estimated sample size ranged from 80-160 participants. After accounting for a potential 20% rate of invalid responses, the target sample size was set at 96-192 participants.

Assessment instruments

General information questionnaire: A self-designed general information questionnaire was used to collect demographic and clinical data, including age, ethnicity, religion, place of residence, educational level, marital status, occupation, personal monthly income, only-child status, parental status, reproductive intentions, family history, disease duration, treatment duration, and types of appearance-related manifestations (e.g., hirsutism, acne, alopecia).

Social Anxiety Subscale of the Self-Consciousness Scale: The Social Anxiety Subscale of the Self-Consciousness Scale[16] was used to assess social anxiety. The scale consists of 6 items rated on a 5-point Likert scale, with item 4 reverse-scored. The total score ranges from 0 to 24, with higher scores indicating greater social anxiety. The Cronbach’s α coefficient of the scale is 0.916.

Perceived Social Support Scale: The Perceived Social Support Scale, developed by Zimet et al[17], was used to evaluate perceived social support. The scale includes three dimensions: Family support, friend support, and other support, with a total of 12 items rated on a 7-point Likert scale. Total scores range from 12-84, with higher scores indicating greater perceived support. Scores of 12-36, 37-60, and 61-84 represent low, moderate, and high levels of support, respectively. The Cronbach’s α coefficient is 0.949[18].

SAQ: The SAQ, developed by Chen et al[19], was used to assess self-acceptance. The questionnaire includes two dimensions (self-evaluation and self-acceptance) and a total of 16 items rated on a 4-point Likert scale. Total scores range from 16-64, with higher scores indicating greater self-acceptance. The Cronbach’s α coefficient is 0.795.

Data collection and quality control

To ensure data quality, all investigators received standardized training prior to data collection. During the survey, participants were provided with uniform instructions regarding the purpose and procedures of the study. For participants with lower educational levels or visual impairments, assistance was provided when necessary.

Data quality control measures included immediate verification of missing responses, dual independent data entry, and logical consistency checks. Questionnaires with patterned responses, logical inconsistencies, or more than 10% missing data were excluded. For questionnaires with less than 10% missing data, missing values were imputed using the mean of the corresponding items.

Statistical analysis

Statistical analyses were performed using SPSS version XX (IBM Corp., Armonk, NY, United States). Continuous variables with normal distribution are presented as mean ± SD, while non-normally distributed variables are presented as median (interquartile range) [M (P25, P75)].

Pearson correlation analysis was used to examine the relationships among self-acceptance, social support, and social anxiety. Mediation analysis was conducted using Model 4 of the PROCESS macro. The mediation model was specified a priori based on the hypothesis that social anxiety may be associated with lower perceived social support, which may in turn be associated with lower self-acceptance. Because the study was cross-sectional, the mediation analysis was interpreted as an exploratory test of indirect association rather than evidence of temporal or causal ordering. Multiple linear regression analysis was performed to identify factors associated with self-acceptance. A two-tailed P value < 0.05 was considered statistically significant.

RESULTS

General characteristics of the study participants

A total of 380 questionnaires were distributed, of which 366 were valid, yielding an effective response rate of 93.6%. All participants were female patients with PCOS. The age ranged from 14 to 56 years, with a mean age of 27.59 ± 6.71 years. Detailed demographic and clinical characteristics are presented in Table 1.

Table 1 General information of polycystic ovary syndrome patients (n = 366).

Variable	Category	n (%)	Self-acceptance score (total)
Age (years)	< 25	131 (35.79)	41.85 ± 7.49
	25-35	196 (53.55)	41.10 ± 7.35
	> 35	39 (10.66)	40 (38.5, 43)
Ethnicity (Han)	No	19 (5.19)	37 (34.5, 40)
	Yes	347 (94.81)	41.60 ± 7.28
Religion	None	152 (41.53)	42.34 ± 6.16
	Yes	214 (58.47)	40.72 ± 7.96
Residence	Rural	221 (60.38)	41.88 ± 7.77
	Urban	145 (39.62)	40.65 ± 6.48
Education	Primary school or below	6 (1.64)	40 (40, 41)
	Junior high school	41 (11.20)	39.63 ± 5.71
	Senior high school/vocational	51 (13.93)	39.22 ± 6.69
	College or above	268 (73.22)	42.12 ± 7.58
Marital status	Unmarried	159 (43.44)	41.78 ± 6.85
	Married/divorced/widowed	207 (56.56)	41.10 ± 7.63
Occupation	Farmer	18 (4.92)	40 (33, 41)
	Service/manual labor	33 (9.02)	39.85 ± 5.94
	Company employee	80 (21.86)	43.61 ± 7.72
	Institution employee	48 (13.11)	41.40 ± 7.65
	Freelancer	74 (20.22)	41.36 ± 7.10
	Student	74 (20.22)	42.65 ± 7.19
	Other	39 (10.66)	37.85 ± 6.45
Monthly income (CNY)	< 3000	24 (6.56)	39.04 ± 5.47
	3000-5999	195 (53.28)	40.41 ± 6.81
	6000-9999	108 (29.51)	42.78 ± 7.98
	≥ 10000	39 (10.66)	43.92 ± 7.55
Only child	No	204 (55.74)	42.18 ± 7.11
	Yes	162 (44.26)	40.41 ± 7.44
Has children	No	189 (51.64)	42.19 ± 6.95
	Yes	177 (48.36)	40.55 ± 7.59
Desire for more children	No	191 (52.19)	40.93 ± 7.62
	Yes	175 (47.81)	41.90 ± 6.92
Family history (PCOS)	No	151 (41.26)	41.93 ± 6.22
	Yes	215 (58.74)	41.01 ± 7.97
Disease duration (years)	0-1	163 (44.54)	41.71 ± 7.59
	1-5	153 (41.80)	41.27 ± 7.31
	> 5	50 (13.66)	40.72 ± 6.33
Treatment duration (years)	0-1	298 (81.42)	41.64 ± 7.28
	1-3	58 (15.85)	40.64 ± 7.83
	> 3	10 (2.73)	38.50 ± 3.03
Number of appearance manifestations	1	86 (23.50)	43.38 ± 6.94
	2	107 (29.23)	41.50 ± 6.24
	3	103 (28.14)	42.08 ± 7.27
	4	51 (13.93)	38.61 ± 7.97
	5	9 (2.46)	36.22 ± 10.29
	6	10 (2.73)	34.90 ± 6.47

PCOS: Polycystic ovary syndrome.

Levels of self-acceptance, social support, and social anxiety

The mean social anxiety score was 18.86 ± 4.50, the mean social support score was 61.27 ± 13.17, and the mean self-acceptance score was 41.39 ± 7.30. The scores for each dimension are shown in Table 2.

Table 2 Scores of self-acceptance, social support, and social anxiety in polycystic ovary syndrome patients (n = 366).

Construct/domain	Item/subscale	Score (mean ± SD)	Mean score per item
Self-acceptance	Self-acceptance	20.78 ± 4.82	2.60 ± 0.60
	Self-evaluation	20.61 ± 4.60	2.58 ± 0.57
	Total score	41.39 ± 7.30	2.59 ± 0.46
Social support	Friend support	20.59 ± 4.74	5.15 ± 1.18
	Family support	20.76 ± 4.97	5.17 ± 1.24
	Other support	19.73 ± 4.69	4.93 ± 1.17
	Total score	61.27 ± 13.17	5.11 ± 1.10
Social anxiety	Social anxiety	18.86 ± 4.50	2.14 ± 0.75

Correlations among self-acceptance, social support, and social anxiety

Pearson correlation analysis showed that self-acceptance was positively correlated with social support (r = 0.429, P < 0.001) and negatively correlated with social anxiety (r = -0.598, P < 0.001). In addition, social support was negatively correlated with social anxiety (r = -0.247, P < 0.001). Detailed correlation coefficients are presented in Figure 1.

Figure 1 Correlation analysis of self-acceptance, social support, and social anxiety in polycystic ovary syndrome patients (n = 366). P < 0.01. SA: Self-acceptance; SE: Self-evaluation; FS: Friend support; FaS: Family support; OS: Other support; SS: Social support; SoA: Social anxiety.

Exploratory indirect association of social anxiety with self-acceptance through social support

To examine the mediating role of social support, social anxiety was entered as the independent variable, self-acceptance as the dependent variable, and social support as the mediator. The analysis controlled for ethnicity, religion, education level, occupation, monthly income, only-child status, parental status, and number of appearance manifestations.

The results showed that social anxiety significantly predicted self-acceptance (β = -0.885, P < 0.001). After including social support in the model, the effect of social anxiety remained significant (β = -0.810, P < 0.001), suggesting a statistically significant indirect association through social support. The indirect effect was -0.074, accounting for 8.36% of the total effect. The mediation model is illustrated in Figure 2, and detailed results are shown in Table 3.

Figure 2 Schematic diagram of the mediating effect of social support between social anxiety and self-acceptance in patients with polycystic ovary syndrome.

Table 3 The mediating effect of social support between social anxiety and self-acceptance in patients with polycystic ovary syndrome.

Effect	Pathway	β	SE	t	P value	95%CI		Effect proportion (%)
						Upper	Lower
Total effect	Social anxiety → self-acceptance	-0.885	0.070	-12.698	0.000	-1.022	-0.748	100
Direct effect	Social anxiety → self-acceptance	-0.810	0.067	-12.054	0.000	-0.942	-0.678	91.64
Indirect effect	Social anxiety → social support → self-acceptance	-0.074	0.030	-	-	-0.140	-0.024	8.36

CI: Confidence interval.

Univariate analysis of factors associated with self-acceptance

Univariate analysis was conducted with self-acceptance as the dependent variable and demographic and clinical variables as independent variables. The results indicated that ethnicity, religion, education level, occupation, monthly income, only-child status, parental status, number of appearance manifestations, social support, and social anxiety were significantly associated with self-acceptance (all P < 0.05). Detailed results are presented in Table 4.

Table 4 Univariate analysis of factors influencing the total self-acceptance score in polycystic ovary syndrome patients.

Variable	Category	F value	P value
Age (years)	< 25	0.419	0.658
	25-35
	> 35
Ethnicity (Han)	No	5.232	0.023
	Yes
Religion	No	4.430	0.036
	Yes
Residence	Rural	2.511	0.114
	Urban
Education level	Primary school or below	3.389	0.018
	Junior high school
	Senior high school/vocational
	College or above
Marital status	Unmarried	0.787	0.376
	Married/divorced/widowed
Occupation	Farmer	4.737	< 0.001
	Service/manual labor
	Company employee
	Institution employee
	Freelancer
	Student
	Other
Monthly income (CNY)	< 3000	5.024	0.002
	3000-5999
	6000-9999
	≥ 10000
Only child	No	5.364	0.021
	Yes
Has children	No	4.641	0.032
	Yes
Desire for more children	No	1.635	0.202
	Yes
Family history (PCOS)	No	1.409	0.236
	Yes
Disease duration (years)	0-1	0.386	0.680
	1-5
	> 5
Treatment duration (years)	0-1	1.264	0.284
	1-3
	> 3
No. of appearance manifestations	1	5.790	< 0.001
	2
	3
	4
	5
	6
Social support		3.887	< 0.001
Social anxiety		13.214	< 0.001

PCOS: Polycystic ovary syndrome.

Multiple linear regression analysis of factors associated with self-acceptance

Multiple linear regression analysis was performed with self-acceptance as the dependent variable. Variables that were significant in the univariate analysis were entered into the model using the stepwise method.

The results showed that ethnicity, number of appearance manifestations, social support, and social anxiety were independent factors associated with self-acceptance. Among these, social anxiety had the strongest negative association, while social support showed a significant positive association.

The model explained 46.0% of the variance in self-acceptance (R² = 0.460), indicating a good model fit. Detailed variable assignments and regression results are presented in Tables 5 and 6, respectively.

Table 5 Influencing factors of self-acceptance in polycystic ovary syndrome patients and assignment descriptions.

Factor	Variable name	Assignment description
Ethnicity (Han)	X1	No = 0; yes = 1
Religion	X2	No = 0; yes = 1
Education level	X3	Primary school or below = 1; junior high school = 2; senior high school or vocational = 3; college or above = 4
Occupation	X4	Dummy variables were created using ”other” as the reference category: Farmer (x41): X41 = 1, x42 = 0, x43 = 0, x44 = 0, x45 = 0, x46 = 0; Service/Manual labor (x42): X41 = 0, x42 = 1, x43 = 0, x44 = 0, x45 = 0, x46 = 0; Company Employee (x43): X41 = 0, x42 = 0, x43 = 1, x44 = 0, x45 = 0, x46 = 0; Institution Employee (x44): X41 = 0, x42 = 0, x43 = 0, x44 = 1, x45 = 0, x46 = 0; Freelancer (x45): X41 = 0, x42 = 0, x43 = 0, x44 = 0, x45 = 1, x46 = 0; Student (x46): X41 = 0, x42 = 0, x43 = 0, x44 = 0, x45 = 0, x46 = 1
Monthly income (CNY)	X5	< 3000 = 1; 3000-5999 = 2; 6000-9999 = 3; ≥ 10000 = 4
Only child	X6	No = 0; yes = 1
Has children	X7	No = 0; yes = 1
No. of appearance manifestations	X8	1 = 1; 2 = 2; 3 = 3; 4 = 4; 5 = 5; 6 = 6

Table 6 Linear regression analysis of factors associated with self-acceptance in patients with polycystic ovary syndrome (n = 366).

Variable	β (understandardized)	β (standardized)	SE	t	P value	95%CI
						Lower	Upper
Constant	46.378		2.406	19.273	< 0.001	41.646	51.111
Ethnicity (Han)	2.721	0.083	1.275	2.134	0.034	0.213	5.229
No. of appearance manifestations	-0.65	-0.108	0.237	-2.736	0.007	-1.117	-0.183
Social support	0.156	0.282	0.022	7.001	< 0.001	0.112	0.200
Social anxiety	-0.822	-0.507	0.066	-12.549	< 0.001	-0.951	-0.693

R² = 0.460, Adjusted R² = 0.454, F = 76.855, P < 0.001. CI: Confidence interval.

DISCUSSION

This study examined the relationships among social anxiety, social support, and self-acceptance in patients with PCOS. The findings indicate that self-acceptance is positively associated with social support and negatively associated with social anxiety. In addition, social support partially mediated the relationship between social anxiety and self-acceptance. Multiple linear regression analysis further identified ethnicity, number of appearance manifestations, social support, and social anxiety as independent factors associated with self-acceptance. These results highlight the complex interplay of psychological and social factors in shaping self-acceptance among patients with PCOS.

Self-acceptance in patients with PCOS

In this study, the level of self-acceptance among patients with PCOS was moderate, which is consistent with previous findings[20]. Patients with PCOS generally experience body image dissatisfaction, impaired self-esteem, and psychological adaptation difficulties. Typical visible external symptoms such as hirsutism, acne, alopecia, and obesity directly damage individuals' body image[2,21], violate traditional stereotypes of femininity, and trigger intense appearance shame.

Cultural factors may further influence these experiences. Based on Chinese local culture, traditional aesthetics advocate a slim figure and smooth skin, while society holds rigid expectations for femininity, marital value, and social belonging. Such cultural influences can amplify the negative labels of PCOS external symptoms, increase appearance pressure and social concerns, and further reduce the level of self-acceptance[14,22]. This also highlights the necessity of incorporating the analysis of local cultural context when evaluating the mental health of the PCOS population.

Social anxiety and social support in PCOS

The results of this study indicate that patients with PCOS have relatively high levels of social anxiety, which is consistent with the conclusion of previous studies that this population has a high prevalence of anxiety symptoms[20]. Appearance-related concerns and reproductive challenges may prompt patients to form negative illness perceptions, regard the disease as a personal flaw, and further develop internalized stigma, leading to excessive worry about others' negative evaluations and ultimately exacerbating social sensitivity, social avoidance, and impairment of social functioning[14,21].

Patients in this study reported relatively high levels of social support. Consistent with previous studies, social support is negatively correlated with social anxiety and serves as a key protective factor for alleviating psychological distress[12]. Positive external support can guide individuals to adjust their perceptions of the disease, reduce stigmatization, help them adopt positive coping styles, alleviate emotional distress, and thereby reduce social anxiety[23].

These findings suggest that interventions aimed at reducing social anxiety and enhancing social support may play an important role in improving psychological outcomes in patients with PCOS.

Interrelationships among social anxiety, social support, and self-acceptance

This study demonstrated significant associations among social anxiety, social support, and self-acceptance. Higher levels of social anxiety were associated with lower self-acceptance, whereas higher levels of social support were associated with greater self-acceptance. These findings are consistent with previous studies. Combined with the self-discrepancy theory and social comparison theory[24-26]: The higher the level of social anxiety, the more likely women with PCOS are to excessively exaggerate their physical symptoms and frequently engage in negative upward social comparison; at the same time, it exacerbates the division between the actual self and the ideal self, leading to constant self-denial and ultimately resulting in a continuous decrease in the level of self-acceptance. This indicates that social anxiety can have a negative impact on self-perception and mental health, while social support can improve coping ability and promote positive self-evaluation[27,28].

Furthermore, social support was negatively associated with social anxiety, suggesting that individuals with stronger support networks may experience less fear of negative evaluation and greater psychological resilience[29-31]. Conversely, individuals with higher levels of social anxiety may be less likely to seek or effectively utilize social support, further reinforcing psychological distress.

Indirect association through social support

The exploratory mediation analysis suggested that perceived social support partly accounted for the association between social anxiety and self-acceptance in patients with PCOS. This finding may be understood from an interpersonal perspective. Patients with higher social anxiety may be more sensitive to negative evaluation and may avoid discussing disease-related concerns with others. This avoidance may reduce their opportunities to obtain emotional reassurance, practical advice, and interpersonal validation. Lower perceived support may then weaken feelings of belonging and positive self-evaluation, thereby contributing to lower self-acceptance[32].

However, the indirect effect was modest, indicating that perceived social support explains only part of the association between social anxiety and self-acceptance. Other psychological and clinical factors, including resilience, coping style, illness perception, family relationships, treatment experience, and cognitive strategies, may also influence self-acceptance. Therefore, social support should be regarded as one possible pathway rather than the sole explanatory mechanism.

It should also be noted that alternative directional models are plausible. For example, stronger perceived social support may reduce social anxiety, and lower social anxiety may subsequently contribute to better self-acceptance. Because the present study used cross-sectional data, the mediation analysis cannot establish temporal sequence or causality. Longitudinal studies and intervention-based designs are needed to clarify the direction and mechanisms of these relationships.

Factors associated with self-acceptance

This study identified ethnicity, number of appearance manifestations, social support, and social anxiety as independent factors associated with self-acceptance. The number of appearance manifestations was negatively associated with self-acceptance, indicating that greater symptom burden is linked to poorer psychological outcomes. This finding is consistent with previous studies demonstrating that visible symptoms such as hirsutism and acne contribute to body dissatisfaction and psychological distress[14].

Ethnicity was also found to be associated with self-acceptance, which may reflect differences in cultural norms and aesthetic expectations. Although the underlying mechanisms require further investigation, this finding suggests that sociocultural factors may play a role in shaping psychological adaptation in patients with PCOS.

Importantly, both social anxiety and social support remained significant predictors in the multivariate model, indicating that internal emotional factors and external social resources independently contribute to self-acceptance. This underscores the need for comprehensive interventions that address both psychological and social dimensions.

Clinical implications

The findings of this study have important clinical implications. Healthcare providers should pay greater attention to the psychological well-being of patients with PCOS, particularly in relation to social anxiety and self-acceptance. Measures such as acceptance and commitment therapy, body image intervention, and cognitive-behavioral intervention help patients accept physical differences, correct negative cognitions, and reduce disease stigma. Meanwhile, a localized social support system should be established: Guide family members to abandon inherent prejudices, resolve stigma and loneliness through peer mutual assistance, and rely on multidisciplinary collaboration to achieve a closed loop of physical and psychological intervention, so as to improve patients’ self-acceptance through “cognitive restructuring + external empowerment” and facilitate their long-term physical and mental recovery.

Limitations

This study has several limitations. First, the cross-sectional design limits the ability to determine temporal or causal relationships among social anxiety, perceived social support, and self-acceptance. Therefore, the mediation analysis should be interpreted as an exploratory indirect association rather than evidence of a causal pathway. Second, all variables were measured using self-report questionnaires, which may introduce recall bias and common method bias. Third, although perceived social support was examined as a potential interpersonal pathway, other relevant factors such as resilience, coping style, family functioning, treatment experience, illness perception, and cognitive appraisal were not fully evaluated. Fourth, the study was conducted in a single clinical setting, which may limit the generalizability of the findings. Future multicenter, longitudinal, and intervention-based studies are needed to verify the temporal ordering of these variables and to examine alternative explanatory models.

CONCLUSION

In conclusion, patients with PCOS exhibited moderate levels of self-acceptance, which were significantly associated with both social anxiety and perceived social support. Exploratory mediation analysis suggested that perceived social support may partly account for the association between social anxiety and self-acceptance. However, because this study used a cross-sectional design, these findings should be interpreted as associations rather than evidence of causal relationships. Overall, the results highlight the importance of integrating psychological assessment and social support strategies into the clinical management of PCOS to improve patient well-being.