Introduction

Polycystic ovary syndrome (PCOS) is a heterogeneous disorder affecting women of the reproductive age (e.g., 15-44 years) which adversely influences the fertility and reproductive health of the women [1,2] and the etiology of PCOS is still an area of active research [3,4]. Further, PCOS reported various complexity with oligomenorrhea (irregular menstrual cycle), amenorrhea (no menstruation), and enlarged ovaries with multiple cysts [5-7]. The prevalence rate of PCOS is highly variable, ranging from 2.2–26% [8]. The rates of PCOS have been reportedly high among Indian women [9-12]. The clinical symptoms of PCOS include obesity, impaired glucose tolerance, type-2 diabetes mellitus, metabolic syndrome, and possibly cardiovascular events, and also causes various mental events such as anxiety and depression [4,13-17]. However, different categories in the clinical manifestations of PCOS have been distinguished according to the Rotterdam criteria [18]. These included PCOS that is characterized by the presence or absence of ovarian cysts with excessive androgen secretion and irregular menstrual periods, and PCOS that is characterized by the presence of increased androgen secretion and multiple cysts, and one with irregular menstruation and multiple cysts [18,19]. Several studies have postulated PCOS as a lifestyle disorder that is linked to the environment and standard of living of women [9-11,20,21]. Thus, an attempt has been made to determine the prevalence and compare of PCOS between rural and urban communities in Kamrup (Metro) and Kamrup (Rural) districts of Assam, Northeast India.

Materials and Methods

The cross-sectional study was carried out in the Pratiksha Hospital of Guwahati, Kamrup (Metro), Northeast India. The study was conducted with approval from the Department of Gynecology, Pratiksha Hospital, Guwahati. The present investigation focused on reproductive women who suffered from PCOS and sought medical assistance related to reproductive health issues and infertility in the hospital. The present study sample comprises 150 Assamese caste women who visited the Department of Gynecology, Pratiksha Hospital, Guwahati, of which 75 women from the urban and 75 women from rural areas of Guwahati utilizing a stratified random sampling method. All the participants were enrolled after obtaining informed consent to participate and the nature of participation in this study. The participants were interviewed to obtain the necessary data separately. All the factors were undertaken based on Rotterdam criteria (2004). Rotterdam criteria are the most widely-used tool for diagnosing PCOS including the presence of irregular menstrual cycle (Oligomenorrhea) or no menstruation (Amenorrhea), hyperandrogenism (signs of hirsutism), serum insulin, serum  Luteinizing hormone (LH) and Follicle stimulating hormone (FSH), and polycystic ovaries on ultrasound [22]. A pre-structured research schedule was used to obtain the socio-economic and demographic data which includes age, family pattern, educational level, and physical labor among the study participants and data on the dietary patterns of the participants were obtained which is categorized as vegetarian and non-vegetarian.

Given that the present study is a hospital-based pilot investigation, the pertinent information on anthropometric measurements, such as height and weight, as well as various biological parameters, such as oligomenorrhea, serum testosterone, serum insulin, serum FSH, and ultrasonography, was obtained from the medical reports of the present study participants. The research participants belonging to the Assamese community aged 18-35 years are included in the study. Women having the symptoms of oligomenorrhea (inter-menstrual interval >35 days or 8 menstrual cycles per year were considered. Women with clinical signs of hirsutism, acne, and polycystic ovarian morphology with 12 or more follicles are observed in at least one ovary and these symptoms were record-based studies along with interviews). However, reproductive women aged between 18 years and 35 years were not included in the present study. The objectives of the present investigation and the nature of participation were explained to the research participants before their participation in the present study. All the participants were enrolled in the present investigation after obtaining informed consent to participate in this study. The data were obtained by using semi-structured questionnaires and anthropometric assessments were collected using a measuring tape, weighing scale, and anthropometer. Socio-demographic and lifestyle data were collected by utilizing a pre-structured schedule which includes the family pattern, education and work activity.

Anthropometric measurements include the height and weight using standard procedures [23]. For the anthropometric measurements of weight and height, the participants were asked to be without footwear and wearing light clothes. Waist circumference (WC) and hip circumferences (HC) were measured by using measuring tape nearest 0.1 cm. For WC superior part of the hip bone was palpated and then measurement tape was encircled around the stomach just above this point and the umbilicus interiorly. The HC was measured by encircling the measuring tape in the broadest part of the hip of the participants. During the time of measurements, the participants were asked to stand in the eye-ear plane, height was measured by using an anthropometric rod nearest to 0.1 cm and weight was measured by using a weighing scale nearest to 0.1 kg. The Body Mass Index (BMI) of research participants was calculated by dividing weight (kg) by height in square meters [24]. BMI was found to be greater than 30.00 kg/m² categories as obese [24]. Work activity levels were also obtained utilizing the self-reported responses based on their physical activity using the self-administered schedule method.

Statistical analysis

The collected data were entered into Microsoft Excel and analyzed in the Statistical Package for Social Sciences (Version 16.0). The continuous variables were presented in terms of descriptive statistics of mean, standard deviation, and range distribution. The Chi-square analysis was performed to determine the frequency differences in categorical variables. A mean comparison between categories was done utilizing t-test analysis. Spearman’s rank correlation coefficient is performed to observe the strength of correlation based on the dietary habits of the studied community. A p-value <0.05 was considered to be statistically significant.

Results

Table 1 shows the socio-economic and demographic results of the studied Assamese caste community that reported the highest percentage of PCOS group within the age group of 24-29 years belonging to urban areas, and the average age was estimated at 25.97±1.84 years (62.71%) and in rural areas the average age was estimated at 26.92±1.76 years (51.02%). The study showed that the majority of urban participants with PCOS are from the nuclear family structure (91.53%) as compared to the joint family (8.47%). The results on the level of education showed a higher proportion of women with PCOS who had passed HSSLC to Bachelor’s degree are from urban areas (47.46%) in comparison to women in rural areas (36.73%).

Table 2 shows the percentage of recent weight gain, obese, non-obese, and work activity level of the studied community, and reported participants with recent weight gain are found to be higher in urban areas (38.66%) as compared to rural areas (9.33%). Obese women are also found to be higher in urban (20.00%, 32.43±1.77) as compared to rural areas (8.00%, 32.74±2.02). The proportion of non-obese PCOS women is found to be higher in rural areas (92.00%, 22.37±2.46) as compared to urban areas (80.00%, 22.24±2.09). Working activity level is higher in rural areas (30.66%) as compared to urban areas (9.33%).

Figure 1: Histogram showing Recent Weight Gain, Obese, non-obese in Rural and Urban areas of Assam, India

Table 3 shows the dietary pattern of the studied community between PCOS and Non-PCOS group which is categorized as vegetarian and non-vegetarian diet. The results showed highest percentage of women suffering from PCOS to be non-vegetarian (88.88%) and the women with PCOS in the category of vegetarian diet to be 11.11%. The Spearman’s rank correlation analysis was performed between the vegetarian and non-vegetarian women having PCOS and the results showed to be rho = 0.8 which signifies a strong correlation between them. Chi-square analysis was also performed to observe the significant difference between women with PCOS in vegetarian and non-vegetarian diet and the result was found to be non-significant (p>0.05).

Table 4 shows the biological parameters based on hirsutism, serum testosterone, serum insulin (raised and normal limit), serum luteinizing hormone (LH), serum follicle-stimulating hormone (FSH), and ultrasonography. The results showed women in urban areas have a higher proportion of hirsutism (33.33%) which indicates a higher androgen activity is prevalent in urban areas. Oligomenorrhea or irregular menstruation is reported to be higher in urban areas (53.33%) as compared to rural areas (14.66%). Raised levels of serum testosterone are found in urban areas (40.00%, 55.32±5.54) and there is no statistical significance between rural and urban areas. Raised serum insulin which is common among PCOS women and can be considered an integral part of the syndrome is found to be in higher proportion in urban areas as compared to rural areas (40.00%, 19.03±5.88) and (34.66%, 18.10±7.08) respectively. Within the normal limit for serum insulin, women with PCOS in urban areas (60.00%, 8.27±3.27) showed a lower percentage as compared to rural (65.33%, 9.46±3.40). Serum luteinizing hormone (LH) beyond the normal range (10-20) mlU/mL is found to be higher in rural areas (32.00%, 11.32±2.02) in comparison to urban areas (24.00%, 11.51±1.92). Within the normal limit range for LH (5-9.9 mIU/mL) is found to be higher in urban areas (76.00%, 7.75±1.31) in comparison to rural areas (68.00%, 7.60±1.64). Serum FSH level was found to be the same both in urban and rural areas. The proportion of patients diagnosed with PCOS through ultrasonography with follicles ≥12 in urban areas versus rural areas (78.66% vs. 60.00%).

Figure 2: Histogram showing Hirsutism, Serum testosterone, Serum Insulin (raised and normal limit), Serum LH, FSH and Ultrasonography reports in Rural and Urban areas of Assam, India.

Discussion

During the reproductive phase of women multiple physiological, anatomical, and psychological changes prevail [10,11,25]. The present investigation has conducted a pilot study to determine the magnitude of PCOS among reproductive women residing in rural and urban areas of Assam, Northeast India (Table 4). The study reported a significantly higher proportion of the associated symptoms of PCOS in the urban areas when compared with the other counterparts to detect and evaluate the risks for diagnosis. However, the prevalence of PCOS depends upon the recruitment process, the criteria used, and the applied methods [10,11,26]. A cross-sectional study conducted in Tamil Nadu, India assessed young adolescents and found a prevalence of 18.00% for PCOS [9] and concluded that the proportion of PCOS cases was higher in urban areas in comparison to rural areas. A study was conducted among young women from a residential college and found that 9.13% of them satisfied the Rotterdam criteria for PCOS in Andhra Pradesh [27]. Bharathi et al. reported the prevalence of PCOS was 6.00% diagnosed by the Rotterdam criteria in community-dwelling women from rural and urban areas of Chennai [11]. International studies report that the prevalence of PCOS is in the range of 4%-10% among women in their reproductive age [28].

The PCOS symptoms of hyperandrogenism, serum insulin resistance, and recent weight gain were commonly observed among the research participants and higher percentages were observed in urban areas (Table 2 and 4). Weight gain and body adiposity are strongly associated with PCOS, and obesity is a well-known factor to worsen the severity of this disorder [29-31]. PCOS is an obesity-related condition, as such weight gain and obesity contribute towards the development of PCOS in women [29,31]. The occurrence of obesity with PCOS which lead to various cardiometabolic dysfunctions can make the pathogenic pathways more challenging [31]. For women who are diagnosed with PCOS, the metabolic and hormonal conditions that are present such as insulin resistance and hyperandrogenism may lead to weight gain and eventually obesity [32]. A study reported that the high percentages of women with PCOS (50-90%) are insulin resistant [33] and weight gain and obesity along with PCOS also promote worsening insulin resistance [34]. The effects of insulin in PCOS then likely contribute towards the development of hyperandrogenemia which also suppresses the sex-hormone-binding globulin that enhances the androgenicity through increased levels of free testosterone [31]. It is observed that girls with high BMI in childhood had an increased risk of oligomenorrhea and diagnosis of PCOS in young adulthood [32,35].

The present study has reported a higher prevalence of PCOS cases within the age group of 24-29 years both in rural and urban areas (Table 1). Several researchers have reported that recent weight gain is the most important symptom of menstrual disorders [9,10]. Menstrual disorders or simple oligomenorrhea might serve as a marker of insulin resistance in patients with PCOS, and insulin resistance may induce oligo-or anovulation and thus menstrual cycle irregularity which exacerbate hyperandrogenemia by disrupting follicular growth [36]. In a study conducted in Uttarakhand, the most common symptom of PCOS was reported to be menstrual irregularity which can otherwise be called oligomenorrhea, and reported in 68% of the women [9]. Another study has recorded even higher estimates of oligomenorrhea at 97.6% in South Indian adolescents aged 15-18 years [27]. A systematic review and meta-analysis reported the lowest rates of hirsutism and hyperandrogenemia in Asian women [37]. The present study showed that 47.99% of the PCOS participants had hirsutism (Table 4). Women with PCOS, develop hirsutism gradually which intensifies with weight gain (Table 2 and 3), and menstrual irregularity like oligomenorrhea was frequently associated with the rapid onset of hirsutism [6].

The present study found that level of work activity is significantly higher in rural areas as compared to urban areas (Table 2). Diet on the other hand also influences the heath of women. Better diet quality enhances the reproductive health of the women. Diet containing high amount of sugar, carbohydrates starch, fat enhances the serum-insulin level and becomes difficult to manage weight loss and in turn affect the women with PCOS (Table 3) [38]. High fiber diet which mostly contain vegetables can help to combat insulin resistance in the women with PCOS by slowing down digestion and reducing the effect of sugar on the blood. Sarkar et al. [38] reported that lifestyle changes have significantly influenced the prevalence of PCOS. Lifestyle modification is a key component of PCOS management and the evidence of higher obesity and longitudinal weight gain, combined with high rates in clinical lifestyle interventions suggests that women with PCOS experience challenges with weight management, implementing and sustaining lifestyle changes [20,21,39]. Fasting serum insulin is also found to be an independent predictor of PCOS (Table 4) and Indian women with PCOS reported higher fasting insulin levels [40].

However, PCOS is often associated with raised insulin resistance as well as with abnormal insulin secretion. These abnormalities, along with obesity, substantially increase the prevalence of glucose intolerance in PCOS. The women are inherently insulin resistant with compensatory hyperinsulinemia and play a central role in the pathogenesis of PCOS [9,10]. Hyperinsulinemia probably increases the ovulation and irregular menstrual cycle [9-11] and women with PCOS have LH and FSH within the (5-20) mIU/ml range [41], and the LH level is found to be higher than that of FSH level causes due to hypothalamic pituitary dysfunction or metabolic disorders [41,42]. Hence, paying attention to early symptoms like irregular menstrual cycles for over a year along with the assessment of weight gain warrants a visit to a gynecologist to facilitate early diagnosis and treatment and to prevent co-morbidities associated with PCOS [21,26,39].

Conclusion

The prevalence of PCOS and its symptoms increase with age, which emphasizes the need for a multidisciplinary approach to identify the disorder at an early age to prevent the occurrence of PCOS. The present investigation concluded that the cause of PCOS mainly emphasized menstrual irregularity and serum insulin levels in association with lifestyle conditions and their socio-economic background. Further, a long-term personalized management program is required for effectively treating individuals with PCOS which can help regulate the symptoms like menstrual irregularities, dermatological issues like hirsutism, and acne, improve fertility, lower the burden of obesity, diabetes and various other metabolic complications and the early steps is to first create awareness and understanding of this disease in the community.

Acknowledgements

The authors gratefully acknowledged the help and active cooperation of the participants and the medical authority during the collection of data. The extended cooperation and support of the Department of Anthropology, Cotton University, is also acknowledged.

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