International Journal of Current Medical And Applied Sciences.vol.1. Issue: 1, 2013, PP 1115 Polycystic Ovarian Syndrome Patients in Relation to Clinical and Endocrine Parameters and Association of BMI with age and fertility: A prospective Observational Study. 1 Swati Shiradkar, 2 Rajesh Dase & 3 Pratima Kartar 1 Professor& Head Dept. of Obstetrics & Gynaecology, MGM s Medical College & Hospital, Aurangabad [MS], INDIA. 2 Assistant Professor, Department of community Medicine, MGM s Medical College & Hospital, Aurangabad [MS], INDIA. 3 Resident, MGM s Medical College & Hospital, Aurangabad [MS], INDIA. Corresponding Email Address: Katarpratima@gmail.com Research Article Subject: Obstetrics & Gynecology. Abstract: Polycystic Ovarian Syndrome (PCOS) is one of the most common endocrine disorders of uncertain etiology effecting almost 510% women of reproductive age (1245 yrs old).83 Polycystic Ovarian Syndrome( PCOS) patients were included in this prospective observational study. Reversal of FSH: LH ratio was seen in 37 PCOS patients out of 58 who had undergone hormonal assay. Most common age of occurrence of PCOS was found between 1520yrs, i.e. 46.98%, patients ages were between 1532 yrs and mean was found to be 21.61±3.51, oligomennorhea was found in 67.4% patients, menorrhagia in 18.07%, secondary amenorrhea in 10.8%.BMI>23 was present in 44.57% patients, overweight were 16.8% patients and obese27.71%.bmi was not found to be associated with fertility and age. Acne and hirsutism was in 28.91% and 24.09% patient s respectively.56.25% was infertile, 63.7% had reversal of FSH: LH ratio. It was found that only one lean PCOS patient had anovulation.insulin resistance was found in 7.69% out of 38 patients. Hypothyroidism was found in 15.8% patients, hyperthyroidism in 3.17%patients.Acanthosis nigricans, renal stones and psoriasis were found in 1.20% patients each. Keywords: Polycystic Ovarian Syndrome, BMI, Clinical, Endocrine etc. Introduction: Polycystic Ovarian Syndrome (PCOS) is the most common female endocrine disorder which is estimated to affect approximately 5 to 10% of women of reproductive age (1245 years old).[10] It is a disorder characterized by an amalgamation of symptoms rather than a single pathognomonic symptom and is of uncertain aetiology although studies have suggested genetic aetiology playing a major role.pcos is attributed as a major factor responsible for menstrual irregularities, infertility, excessive amounts or effects of androgenic hormones resulting in acne, hirsutism, insulin resistance, obesity, type 2 diabetes, high cholesterol levels in reproductive age group. These women are also at increased risk of developing endometrial, breast and ovarian carcinoma. Studies have shown that hirsutism is seen in 69% of patients whereas acne is seen in2735% [10].Obesity is diagnosed mainly by measuring BMI and waist hip ratio.pcos women have central obesity and the waist to hip ratio is increased. Relationship between obesity and PCOS is a very complicated one as some studies suggest prevalence of PCOS to be rising because of the increase in obesity and show 50% of PCOS women to be obese, while some studies suggest that they are not related. Major diagnostic tests for PCOS are pelvic sonography and hormonal assay.luetinizing hormone is shown to be elevated in many PCOS patients. In spite of improved and advanced diagnostic facilities, PCOS is not diagnosed properly and timely which can lead to long term effects on health. This is a prospective observational study of PCOS patients in relation to clinical and endocrine parameters such as age, symptoms, BMI, hormonal study, fertility and also finding the association of BMI with other parameters such as age and fertility. Copyright @ 2013 Logic Publications, IJCMAAS,EISSN:23219335,ISSN:23219327(Print) pagei 11
Swati Shiradkar, Rajesh Dase & Pratima Kartar Material and Methodology:This is a prospective observational study including 83 patients who were diagnosed as PCOS on the basis of history of menstrual irregularities, features of hyperandrogenism like acne and hirsutism and ultrasonography (suggesting polycystic ovaries).58 patients were further evaluated for hormonal assays. The diagnosis was based on Rotterdam criteria which states that to be diagnosed as PCOS,two out of these three following features should be present 1)irregular or absent ovulation 2) features of hyperandrogenism 3) polycystic ovaries on USG.Other condions such as androgensecreating tumours or Cushing s syndrome were ruled out. The patients were included in the study on the outpatient department basis. Detail history of the patients was taken including menstrual history (regularbleeding interval from between 2135 days), Oligomennorhea (bleeding interval between 35days 6 months), secondaryamenorrhea (bleeding interval >6months), Observation & Results: primary amenorrhea (no menarche), menorrhagia (heavy bleeding) and obstetric history, which included fertility status of the patient as follows fertile, infertile. Obstetric history of 32 (married) patients out of 83 patients was taken.51 patients were unmarried. Any other medical history was noted down. Examination included measuring BMI(according to the Indian standards)weight in kgs/height in cms squared, any abnormality like acne, psoriasis, hirsutism.bmi 2324.9 was considered as overweight, above 25 was obese.bmi <18 was considered underweight and between 18 and 22.9 was considered normal. Laboratory investigations were done on second or third day of the menstrual cycle. Reversal of FSH:LH ratio was considered significant for PCOS.Lean PCOS patients(bmi<18) with reversal of FSH:LH ratio was also evaluated. Insulin resistance was considered in patients having serum insulin >25 m IU / ml. Normal values ( 225 m IU/ml). Table 1: Observation of PCOS patients in various parameters: AGE (n=83) Number of Patients (%) 1520 39 (46.98%) 2125 32 (38.55%) 2630 12 (14.47%) >30 00 (00%) SYMPTOMS 1.MENSTRUAL CYCLE (n=83) REGULAR 02 (2.40%) OLIGOMENORRHEA 56 (67.4%) SECONDARY AMENORRHEA 09 (10.8%) PRIMARY AMENORRHEA 01 (1.20%) MENORRHAGIA 15 (18.07%) 2. ACNE (n=83) 24 (28.91%) 3. HIRSUTISM (n=83) 20 (24.09%) 4.THYROID ABNORMALITY (n=63) HYPERTHYROIDISM 02 (3.17%) HYPOTHYROIDISM 10 (15.8%) 5.RENAL STONES 01 (1.204%) 6.PSORIASIS 01 (1.204%) 7.ACANTHOSIS NIGRICANS 01 (1.204%) 8. INFERTILITY (n=32) 18 (56.25%) BMI (n=83) <18(UNDERWEIGHT) 11 (13.25%) 1822.9 (NORMAL) 35 (42.16%) 2324.9 (OVERWEIGHT) 14 (16.8%) 25 or above ( OBESE) 23 (27.71%) REVERSAL OF FSH:LH ratio (n=58) 37 (63.7%) INSULIN RESISTANCE (n=39) 03 (7.69%) ( ) percentage. &.n is Total number of patients available for evaluation Copyright@2013,Logic Publications: International Journal of Current Medical And Applied Sciences. [IJCMAAS]
International Journal of Current Medical And Applied Sciences.vol.1. Issue: 1, 2013. In this study 83 Polycystic Ovarian Syndrome (PCOS) patients were included. All 83 patients were evaluated for the age criteria. It was found that PCOS is most common in age between 1520yrs, i.e. 46.98%.Patients ages were between 1532yrs and the mean was 21.61±3.51.Oligomennorhea was found in 67.4% of patients and only 2.40% had regular menstrual cycles. Primary and secondary amenorrhea was found only in 1.20% and 10.8% of the patients respectively. Menorrhagia occurred in 18.07%. 16.8% patients were overweight and 27.71% obese.bmi>23 was present in 44.57% of patients.13.25% were found to be underweight. Acne was present in 28.91% of patients and hirsutism in 24.09%.Hyperthyroidism, hypothyroidism, renal stones and skin diseases such as psoriasi and acanthosis nigricans were detected.63 patients were available for the thyroid tests. Hypothyroidism was prevalent in 15.8%. Renal stones, psoriasis and acanthosis nigricans accounted only around 1.204% each. 32 married women were evaluated for fertility.56.25% was infertile.58 PCOS patients underwent hormonal assay.63.7% had reversal of FSH:LH ratio. Some associated conditions were found too. One patient was schizophrenic and one had myometrial fibroid. Some patients were tested sonographically for endometrial thickness, around 15 patients had endometrial hyperplasia and 3 had hydrosalpinx Out of the 37 patients with reversal of FSH:LH ratio, only one patient had BMI<18.Hence only one lean PCOS patient was found to have anovulation.out of the 39 PCOS patients tested for Insulin resistance was found in 7.69 %. Table 2: Association of BMI with Age AGE BMI (n=83) 1520 2125 2630 >30 <18 (Under weight) 1822.9 (Normal) 2324.9 (Overweig ht) =/>25 (Obese) 06 (19.34%) 16 (41.02%) 06 (19.34%) 11 (28.20%) Total 39 Chisquare value Pvalue 04 (12.5%) 15 (46.87% ) 05 (15.62% ) 08 32 1.94 02 (16.67%) 03 03 P=0.886 NS 04 (33.33%) 12 In age group 1520 years 41.02% patient were having Normal BMI, 28.20% were obese, and 19.34% were underweight & overweight. In 2125 years agegroup 46.87% were having normal BMI, 25% were obese, 15.62% & 12.5% were overweight & underweight respectively. Where as in agegroup 2630 years, 33.33% were obese, 25% were normal & overweight & 16.67% were underweight. There was no association between Agegroup & BMI (p=0.886). In infertile 18 married patients, 66.67% patients were having Normal BMI, 22.22% were underweight, and Table 3: Association of BMI with Fertility BMI FERTILITY ( n=32) INFERTILE FERTILE <18 04(22.22%) 04(28.57%) (Under weight) 1822.9 12(66.67%) 05 (35.71%) (Normal) 2324.9 01(5.56%) 02(14.28%) (Overweight) =/>25 01(5.56%) 03(21.43%) (Obese) Total 18 14 Chisquare value 3.77 Pvalue 5.56% were overweight & obese. Where as in 14 fertile married patients, 35.71% patients were having Normal BMI, 28.57% were underweight, and 21.43 & 14.28 were obese & overweight. There was no association between fertility & BMI (p=0.414). Discussion: P=0.414 NS This study comprises of 83 Polycystic Ovarian Syndrome (PCOS) patients with age between 15 32yrs with mean as 21.61+/3.51.K.K.Maryam et al. (2012) study included age group between 1438 yrs and found mean to be 23.67+/6.34 [5]. According to our study oligomenorrhea is the most common complaint occurring in 67.4% of the patients followed by menorrhagia in 18.07% and then secondary amenorrhea in 10.8%.Primary amenorrhea was found only 1.20% patients and 2.40% had regular menstrual cycles. Copyright@ 2013 Logic Publications, IJCMAAS, EISSN:23319335,ISSN:23219327(print) Page 13
Swati Shiradkar, Rajesh Dase & Pratima Kartar oligomenorr hea Sec.amen orrhea Regular cycles Our study 67.4% 10.8% 2.40% F.Nazir 52.90% 32.40% 14.70% (2008) R.Yousouf et al(2012) 71% A study by R Yousouf et al (2012) found oligomenorrhea in 71%patients [4 ]which almost matches with our study,wheareas prevalence of secondary amenorrhea is decreased comparatively in our study. Many studies consider obesity as one of the most important sign of PCOS.We found out in our study that 42.16% had normal weight, overweight were 16.8%,obese were 27.71% and BMI>/=23(overweight or obese)were 44.57% patients. NORM AL BMI OVERWE IGHT OBESE OW+ OBE SE Our study 42.16% 16.8% 27.71% 44.57 % A.Kalra(2006) 40% 44.6% 15.3% 60% F.Nazir (2008) 29.41% 29.41% 38.24% D. Popescu 60.71% 39.29 (2008) % K.K.Maryam 17.24% et al (2012) A. Prakash et al 42% 58% (2012) BMI values as per the fixed international standards. <19underweight,>19 to <25 normal, >25 overweight,> 30obese,>40 very obese.rest of the studies used BMI according to the Indian standards. We also studied association of BMI with age and fertility. Age and fertility were not found to be associated with BMI.K.K.Maryam et al (2012) found no association of BMI with age [5]. D. Popsscu (2008) found BMI to be associated with fertility and BMI could cause infertility[2]. In our study acne was found in 28.91% patients. Studies have shown that prevalence of acne in PCOS patients is around 1034%[13].Hirsutism is seen in 24.09% in this study, whereas a study conducted by R. Yousouf et al suggested 31% patients to have hirsutism[4], there is not much difference between the findings of both the studies. Some studies have even found 63% patients with hirsutism. Infertility was found to be 56.25%in this study..that is more than 50%.R. Yousouf et al found 74% patients with infertility in their study [4].Reversal of FSH:LH ratio was found in 63.7% patients of the 58 patients who underwent hormonal assay. It has been found that increased amount of insulin stimulates the ovaries which can lead to the production of excess male hormones testosterone which can prevent the ovaries from releasing an egg each month & therefore cause infertility. High levels of insulin also lead to increased conversion of androgens to estrogen,hence disrupting the balance between the two and having a direct effect on weight gain and also the formation of cystic follicles or cysts in the ovary.in our study 39 patients were tested for insulin resistance and 7.69% patients were found to be resistant and all were obese.tayebe Hemati et al(2011) found 35.94% PCOS patients to be insulin resistant in their study[12]. K.K.Maryam et al (2012) found 45% patients having insulin resistance to be above normal BMI[5],39% of them were obese and 6% overweight [5]. Kidney stones have also been found in some PCOS patients. It has been suggested that overweight PCOS patients suffering from renal stones have increased chances of developing high blood pressure (hypertension) which causes stroke, which kills more women than men each year[9]. A study comprising of 1458 PCOS patients found out 8 patients to be suffering from kidney stones(0.55%) [11] which is almost similar to our finding(1.204%).some PCOS patients have hypothyroidism and some hypothyroid women are misdiagnosed as PCOS.A recent study proved that hypothyroidism is related to PCOS,ovarian enlargement and cyst formation. Thyroid replacement therapy improved menstrual irregularities in 50% of PCOS patients and regressed ovarian volume and cysts.[14] In our study 15.8% patients have hypothyroidism. Psoriasis was found in 0.602% in a study comprising 2157 PCOS patients, whereas in this study 1.204% of patients suffer from it [15].Acanthosis nigricans was found in 1 patient only who had very high BMI(>25,obese),also had diabetes mellitus 2 and secondary amenorrhoea. Associated factors such as endometrial hyperplasia, hydrosalpix were also found in the patients. One patient was found to be schizophrenic Copyright@2013,Logic Publications: International Journal of Current Medical And Applied Sciences. [IJCMAAS]
International Journal of Current Medical And Applied Sciences.vol.1. Issue: 1, 2013. Conclusion: It conclude that age group between 15 and 30 yrs,menstrual irregularities especially oligomennorhea, androgenic factors such as acne and hirsutism, BMI,infertility,insulin resistance and reversal of the FSH/LH ratio are important PCOS parameters and should be kept in mind when considering PCOS as a possible diagnosis.bmi has been shown to have no association with age and fertility. Associated conditions such as renal stones, hypothyroidism, hyperthyroidism, psoriasis, acanthosis nigricans, hydrosalpinx, myometrial fibroid, endometrial hyperplasia and schizophrenia have also been found to be present in few patients. Recommendations: Hence it is strongly recommended that timely diagnosis and treatment is essential for the wellbeing of the woman with PCOS.Even lifestyle modifications (such as physical activities, dietary modifications, reducing stress and preventing alcohol/smoking) should be encouraged in order to reduce obesity, risk factors due to Polycystic Ovarian Syndrome (PCOS) and for psychological well being. References: clinical.hormonal,metabolic assessment in relation to BMI:,Indian Journal Endocrinol Metab,2012,vol 16(6), pp 996999. 8. A.Kalra,S. Nair,L. Rai,: Association of obesity & insulin resistance with dyslipidemia in Indian women with PCOS:,Indian journal of Medical Sciences,Nov 2006,Vol60,No.11,pp447448. 9. PCOS weight gain, Kidney Stones & High blood pressure: PCOS Support Blog.com,Dec 23 rd,2011. 10. Polycystic Ovarian Syndrome, Wikipedia.com 11. Could PCOS cause kidney stones: ehealthme.com (Real World study) 12. T.Hemati,N.Moghadami,F.Davari,B.Salmanian,P.Ja vadian,:high plasma homocysteine and insulin resistance in patients with polycystic ovarian syndrome:,iranian journal of Reproductive Medicine,2011 Vol.9.No.3.pp:223228. 13. S.S.Chuan, R.Jeffrey Chang,: Polycystic ovary syndrome and Acne:Skintherapyletter.com,2010, 14. S.Avdiushko,:Connection between hypothyroidism and pcos:, Hormones matter.com,october2012 15. Could PCOS cause psoriasis: ehealthme.com (Realworld study). 1. Howkin s & Bourne Shaw : Polycystic ovarian syndrome (PCOS) OR Disease (PCOD)Disorders of the ovary and benign tumours :Textbook of Gyenacology,14 th edition, New Delhi:2010,pp 369 372 2. Wikipedia.com 3. D. Popescu,:Correlations between obesity and polycystic ovarian syndrome:2008, 4. R. Yousouf,M. Khan,Z. Kounsar,S. Ahangar,W. A. Lone, :Polycystic ovarian syndrome: Clinical correlation with biochemical status:, Journal of Medicine & Healthcare, May2012,Vol.3,No.5,pp.245248. 5. K. K. Maryam, N. A. Pour, A. Safari and R. Roozegar,: Body mass index (BMI) related insulin resistance in polycystic ovarian syndrome among patients referred to gynecology clinic of Imam Reza hospital Tehran, Iran: Journal of Clinical Medicine & Research, October 2012,Vol.4(7),pp 8488. 6. F. Nazir,: Clinical and genetic studies of Polycystic ovarian syndrome:, Pakistan Research Repository.com,2008. 7. A.Prakash, P. Saxena,A. Nigam,A.Mishra,: PCOS:Is obesity a sine qua non?a Copyright@ 2013 Logic Publications, IJCMAAS, EISSN:23319335,ISSN:23219327(print) Page 15