The worldwide impact of AUB in the reproductive years is noteworthy, with a prevalence of approximately 3–30% among reproductive-aged women. Many of the published studies are restricted to estimates of the prevalence of the symptoms of HMB. When other symptoms, particularly those of irregular and intermenstrual bleeding are included, the prevalence rises to 35% or higher . AUB not only gives discomfort and anxiety to women, but it can be accompanied by depression when there is persistent AUB. In AUB patients who visit the hospital with anxiety and depression, proper management is necessary, but the importance of psychological and risk evaluations has been underestimated.
Menstrual-related problems are associated with substantial psychological distress, a finding that confirms results reported in clinical cases and strongly supports the claim that menstrual-related problems pose important public health implications [18, 19]. Mood and anxiety disorders, particularly major depression (15.6%), generalized anxiety disorder (18.8%), and obsessive-compulsive disorder (22.9%) were frequently observed in patients with AUB .
Strine et al.  suggested that menstrual-related problems in women pose considerable public health implications as they were reported by nearly 19% of U.S. women. Additionally, those with menstrual-related problems are between 1.7 and 3.0 times more likely to report insomnia, sleepiness, recurrent pain, sadness, nervousness, restlessness, hopelessness, and worthlessness.
The lifetime prevalence of mental illness in Koreans is known to be 25.4%. According to an epidemiological survey of mental disorders in Korea conducted by the Ministry of Health and Welfare, the estimated lifetime prevalence of anxiety disorders for Korean adults was 9.3% (male 6.7%, female 11.7%) and the 1-year prevalence of anxiety disorders in Korean adults was 5.7% (male 3.8%, female 7.5%) . The prevalence of major depression is quite wide and ranges between 8.2 and 67%. According to the level of mental health among Koreans, the rate of experience of depression was 13%, and the prevalence of depression was 5.0% [1, 20].
More women with AUB in our study had anxiety as measured by the K-BAI (7.5% in the general population and 37.9% in this study) and depression as measured by the K-BDI-II (5% in the general population and 19.5% in this study). Our study found that the prevalence of anxiety and depression was higher in AUB patients.
Mood and anxiety disorders associated with irregular menstruation may also be associated with different etiologies. It is well-documented that depression is seen more frequently in women during premenstrual, postnatal, and menopausal periods due to the fluctuations in hormonal levels during these periods . However, it is difficult to clearly confirm the relationship between psychological aspects and physical symptoms.
When all factors are taken into consideration, a bidirectional relationship between AUB and psychiatric disorders may be observed. Kayhan et al.  reported that psychiatric disorders play a more important role than AUB because the latter frequently occurs together with stressful events and psychiatric disorders, but once these events or disorders are resolved, the menstrual cycle becomes regular again. Although the relationship between AUB and anxiety, depression is difficult to know clearly, research on the association has important implications for women's health.
We hypothesized that age, BMI, obesity, abortion history, surgery-related delivery or gynecologic problems, menstruation cycles, dysmenorrhea, anemia, and medical disorders may be associated with anxiety and depression in the presence of AUB, but there was no clear relationship in our study.
In this study, anxiety and depression showed a moderately positive correlation with AUB, indicating that it is necessary to closely monitor and manage whether anxiety or depression accompany women with AUB.
Women with past mood disorders were more likely to report heavy bleeding symptoms, independent of known risk factors for heavy bleeding, such as high BMI, fibroids, early perimenopause, and mood disorders, occurring simultaneously with heavy bleeding. Mood disorder has been shown to be a risk factor for the subsequent development of important health disorders, such as diabetes, cardiovascular disease, pain, backache, and dizziness [3, 22].
In the case of AUB, anxiety increased with a history of abortion, and anxiety scores were low in women with a history of C/sec. Although it is difficult to know the relationship clearly, it seems that anxiety increases when a loss is experienced, such as abortion, and sensitivity to anxiety decreases when a major operation such as C/sec has already been performed. However, it seems that parity, irregular menstruation, and dysmenorrhea did not significantly affect anxiety, especially in the presence of AUB in our study.
The degree of depression was increased in women with a history of minor surgery, which seemed to be because it affected patient mood in the presence of AUB. However, minor surgery did not appear to affect anxiety.
There were several limitations to our study. We were unable to determine if psychological distress and adverse health behaviors were related to AUB, and unable to exactly identify where during the menstrual cycle the psychological and behavioral associations were more evident. The K-BAI and K-BDI-II were not originally developed as diagnostic tools. Our study could not conclude a causal relationship between menstrual-related problems, emotional well-being, and psychological problems.
The women who participated in the survey are likely to have sampling bias error because AUB symptoms interfere with daily life and all participated women were admitted hospital due to management of AUB. Due to a lack of other similar studies in the literature, an analysis of the difficulties and limitations of the current study in comparison to other studies was not possible.