Awareness of Lifestyle Modifications in the Management of PCOS: A Population-Based Descriptive Cross-Sectional Study

DOI: https://doi.org/10.21203/rs.3.rs-1378647/v1

Abstract

Introduction: Polycystic ovarian syndrome(PCOS) is a rapidly emerging endocrine disorder affecting women of all ages. Simple lifestyle modifications can help women to combat the disorder.

Objective: To assess the knowledge among reproductive women regarding the risk factors, symptoms, complications, and management of PCOS and their source of knowledge to develop an educational tool to be used at the community level.

Results: A total of 334 women participated. The mean age was 28.70±6.29 years. Around 9.3% of the participants were already diagnosed with PCOS. Around 43.4% of women have heard about PCOS. The Source of their information was a doctor (26.6%), internet (6.28%), teachers (5.6%), and friends (4.7%). Knowledge regarding risk factors revealed that obesity (33.5%), unhealthy dietary habits (35%), and genetic predisposition (40.7%) were thought as risk factors. Regarding complications participants were aware that PCOS is associated with increased risk of subfertility (40.1%), abortions (34.4%), diabetes (28.7% ), hypertension (31.7%),cardiovascular disease (33.5%), endometrial carcinoma (35.9%) and psychological (37.1% ) . Total 37.1% were aware that eating healthy and 41% knew that weight reduction can help in the management of PCOS. Around 60.5% of women showed poor knowledge, 14.7% fair knowledge, and 24.9% good knowledge regarding PCOS. Education and occupation status was significantly related to the knowledge score (P≤0.001) about the PCOS.

Conclusion: To reduce the burden of PCOS behavioral changes in terms of regular exercise, healthy dietary habits and stress management techniques need to be incorporated from very early life. 

Introduction

Polycystic ovarian syndrome (PCOS) has emerged as a new epidemic in the last few decades. The prevalence of PCOS varies between 6-25% globally1-6. Due to the complex presentation of the disease diagnosis is difficult and is often delayed 7-9. Women with PCOS may present with menstrual irregularities, subfertility, obesity, dermatological manifestations like hirsutism and acne. The long-term sequelae of the disorder include metabolic disorders, impaired glucose tolerance, diabetes, hypertension, and cardiovascular disorders. Due to chronic anovulation and the unopposed effect of estrogen on the uterus these women are at higher risk of developing endometrial cancer later in life. Adolescent women with PCOS may suffer from various psychological issues like depression, anxiety and sleep disturbances, and body image disorders which significantly affect their quality of life. The exact etiology of the disorder is not known however oxidative stress, genetic predisposition, certain gene polymorphism are thought to be the culprit for PCOS 10-14. Various environmental factors, sedentary lifestyles, unhealthy eating habits are also seen to be related. Rotterdam criteria, National Institute of Health (NIH) and androgen excess and PCOS Society criteria are used to diagnose the disorder. No permanent cure for PCOS is possible. The management is usually targeted to treat the symptoms and to prevent long-term sequelae. Lifestyle modifications in terms of adopting an active lifestyle, healthy and balanced diet, avoiding junk and unhealthy eating habits, weight reduction in those who are overweight and stress management has been seen to be effective. Even in those who need pharmacotherapy, drug therapy coupled with lifestyle modification has shown better results15-16. 

This study was planned to assess the level of knowledge among the reproductive age woman about PCOS, risk factors and complications, and the source of information about the disease so that an education-level tools to disseminate the awareness regarding PCOS at the community level can be formulated. 

Methodology

A population-based descriptive cross-sectional study was done in reproductive age women attending the Gynaecological OPD at a tertiary care hospital. Ethical committee clearance was taken from the ethical committee of the institute. Participants were briefed about the purpose of the study in the local language and a written informed consent was then taken. A pre-validated well-structured questionnaire containing 40 items was administered. The purpose of the study was explained to the participants. A total of 350 women participated. Out of all-around 16 forms were incomplete so were not included in the final analysis. Question 1-7 included the basic demographic data of women, 8-11 included related to the menstrual history of the women, 12-18 included a question related to the presence of any symptom related to PCOS, 19-30 regarding knowledge about PCOS, source of information, its symptoms and complications related to it, 31-36 included questions regarding their knowledge about the prevention and treatment of the PCOS related symptoms and complication. Questions 37-40 include the information regarding the healthy lifestyle they are practicing in their routine life. 

Statistical Methods: In the present study descriptive and inferential statistical analysis has been carried out. Results on continuous measurements are presented as Mean ± SD (Min-Max). Results on categorical measurements are presented as Number (%). Significance is assessed at a 5 % level of significance. The one-way analysis of variance (ANOVA) is employed to determine whether there are any statistically significant differences between the means of three or more independent (unrelated) groups. The significance of the parameters on the categorical scale between two or more groups has been calculated using Chi-square/ Fisher Exact test. The non-parametric setting was used for Qualitative data analysis. Fisher Exact test is used when cell samples are very small. P-value: 0.05<P<0.10 was taken as suggestive significant, P value:0.01<P £ 0.05 as moderately significant and P-value: P£0.01as strongly significant. Statistical software namely SPSS 22.0, and R environment ver.3.2.2 were used for the analysis of the data, and Microsoft Word and Excel have been used to generate graphs, tables, etc.

Results

The mean age of the study population was 28.70±6.29 years. Most of the women in the study group were between 21-30 years (61.4%) followed by 31-40 years (30.5%), 41-50 years (5.4%), and 15-20 years (2.7%). Around 49.4% of the women had normal BMI (18.5-24.9),13.5 % were underweight (<18.5), 28.7% overweight (25.0-29.9) and 8.4% obese (>30). Most of the women in the study group were graduates (42.8%), 8.4% postgraduates, 22.2% high school pass and 8.1% had received primary education. Around 18.6% of the participants were illiterate. Most of them were housewives (49.4%), around 26.95 % were working and 23.6% were students. The majority were married (61.7%). When asked about the menstrual history mean age of menarche was found to be 13.48±1years. Mean cycle length was 21.56+3.28 days with most of them having cycle length of 21-35 days (64.37%), <21 days (8.9%), 35-60 days (23.35%) and > 60 days (1.49%) (Tablet I). Among all 35.6%  of the participants experienced a change in the cycle length in the past 6 months. Around 9% said they were having frequent cycles (<21 days), 24.8% reported delayed cycles (>35 days), 1.5 %   scanty flow, and 0.3% heavy flow. Out of all 9.8% of the participants had taken medication for regularisation of their menstrual cycles. Among the study participants, 6.3 % experienced weight gain, 1.2% weight loss in the past 6 months. However, the majority experienced no change in their weight in the previous three months. Around 2.4% of women experienced excessive hair growth on the body, 9% said they were having excessive hair fall, 8.7% reported acne and needed treatment. Around 8.1 % of the women were desirous of pregnancy however 6.6% were having some difficulty in spontaneous conception and 4.4% were already on treatment (Table II).  In the study group, 9.3% of the participant were already diagnosed to have PCOS. While assessing the knowledge about PCOS researchers found that only 43.4% of the women had heard about PCOS and the most common source of their information was a doctor (26.6%) followed by the internet (6.28%), teachers (5.6%), and friend (4.7%). Assessment of knowledge for risk factors showed that a significant proportion of women were aware of the association of obesity (33.5%), unhealthy dietary habits (35%), and genetic predisposition (40.7%) with PCOS. When asked about complications and long term sequelae of PCOS  40.1% of women said that patients with PCOS can have problems in conception, 34.4% said there can be increased chances of abortion in PCOS patients, 28.7% said women with PCOS are prone to develop diabetes, 31.7% said they can have hypertension, 33.5% said it can raise the chances of cardiovascular disease, 35.9% said there could be an association with endometrial carcinoma and 37.1 % said it could be related to psychological problems, sleep disturbances, body image disorder and anxiety in women (Table III). While assessing their knowledge regarding management researchers found that around 37.1% were aware that eating a healthy and balanced diet can be one of the management methods, 41% believed weight reduction could help and 35.6 % said trying ways to reduce stress could be one of the methods to manage the symptoms of PCOS. However, 34.1% said only medications can treat the condition and 2.7% believed only surgery can treat PCOS (Table III). Around 60.5% of women scored <5 out of 14 (poor knowledge), 14.7% scores between 6-10 (fair knowledge), and 24.9% scored between 11-14 (good knowledge). When we analyzed the score categories with the education and occupation status of the women it was seen that those who are graduate and postgraduates have scored better and the results are statistically significant (P≤0.001) and those who are working had better knowledge followed by students (P≤0.001) (Table IV & V). Lastly, we inquired about the healthy lifestyle practices they are routinely following in their day-to-day life. It was found around 23.9% of women were doing some kind of exercise. Out of all 9.8% go for walk daily, 1.76% were taking weight training, 2.69% were doing aerobic exercises, 23% were doing yoga and 2.64% were doing swimming. Around 11.7% of the study population was practicing meditation as stress-relieving management. Only 14.67% of the women said they eat junk rarely however 27.54% said they very often eat junk food and 57.78 said they sometimes eat junk food.

Discussion

Polycystic ovarian syndrome is a complex endocrine disorder affecting women across all the stages of their life. Adolescent girls often present with menstrual irregularities, acne, hirsutism, and obesity which can further lead to body image disorders, low self-esteem, anxiety, and depression in them. Women with PCOS may have difficulty in spontaneous conception and often need fertility treatment. These women can also experience repeated pregnancy losses. Later in life, they are at increased risk of diabetes, hypertension, and cardiovascular disorders. Due to the unopposed estrogen, they are at risk of development of endometrial hyperplasia and endometrial cancer. Management often includes measures targeted to reduce the symptoms or to prevent the complications associated with the disorder. There is no permanent cure but the lifestyle modifications in PCOS women like weight reduction, exercise, meditation, and a healthy diet is seen to help them to fight their symptoms. Hence it is very important to spread knowledge and awareness in the community regarding the risk factors, symptoms, complications when to seek help and whom to seek help from. Along with this importance adopting a healthy lifestyle in today's world where stress, sedentary lifestyle, and preserved food have become the new norm should also be stressed upon. 

 In the present study, researchers found that a significant proportion of women (43.4%) have heard about the term PCOS. The above findings are similar to the findings published by Alessa et al.17 where researchers found that 56.7% of the women had heard about PCOS. These findings show that a significant percentage of women had heard about the disorder but still it is not 100%  and there is a lot that needs to be done to disseminate this knowledge among the community. The most common source of information in our study was health care provider/doctor (26.6%) followed by internet (6.28%), teacher (5.6%), and friends (4.7%) however the most common source of information in the study conducted by Alessa et al. was internet (21.3%) followed by patients (10.4%), doctors (10.8%) and books (3%). Another study by Rao et al. found that 83.7% of women got the information from doctors, 29.4% family, 25% friends. Government websites and PCOS support groups were the other mentioned sources in the study. The difference could be because in our study the study participants were those attending the Gynaecological OPD for various reasons however the study done by Alessa et al. and Rao et al. included college students. Around 9.3% of the study population was already diagnosed to have PCOS in contrast to 15.3% of the women in the Study by Alessa et al. and 28.5% in a study by Rao et al.18 The difference can be explained by the regional variation in the distribution and variation in the sample size of the studies. In the present study, researchers found that the women who were not diagnosed with PCOS also had certain symptoms which need evaluation to rule out PCOS as 35.6% had change in their cycles, 6.3% reported weight gain, 2.4% had excessive hair growth, 9% had excessive hair fall, 8.7% had acne,6.6% had a problem in conception. Rao et al. in their study also found that around 40.5% of women not formally diagnosed with PCOS had PCOS-like symptoms. While assessing knowledge regarding risk factors associated with PCOS 33.3%  were aware that excess weight is associated with PCOS and 35% knew unhealthy eating habits can be related to PCOS. Around 32 % said it is familial. When asked regarding complications related to PCOS it is seen that similar to the study by Alessa et al. in the present study participants are aware regarding its association with subfertility (40% Vs 39%), diabetes (28.7% vs 14.5%), endometrial cancer (35.9% vs 30.2%) and psychological disturbances (37.1%vs 34.1% ). Assessment about management knowledge showed that in both the studies (37.1% vs 39.9%)  the participants are aware that exercise and losing weight can help reduce the symptoms and related complications. Around 41% of the women are aware that eating a healthy and balanced diet is helpful and the findings are similar to the finding in the study by Alessa et al where 34.2% were aware of the benefits of eating healthy food. In the present study around 34%, of women said that medications and surgery are the other options to manage PCOS while in a study by Alessa et al around 29.4% of women were aware of the medical management. In the Study done by Alessa et al. author has not mentioned the awareness about the surgical procedures for PCOS. In both the studies it is seen that more the level of education more was the knowledge score.

With increasing education level the percentage of women who know about the risk factors, symptoms, complications, and management is also rising across the globe but is this knowledge getting translated into actual practice? In this study only 23.95% of the study participants were exercising daily, only 11.7% were meditating and 14.7% said they rarely take junk food. The finding suggests that only disseminated knowledge and awareness are not enough it requires a tremendous effort to bring about the behavioral changes at the community level. 

To bring about these behavioral changes authors suggest that the knowledge and awareness about a healthy lifestyle need to be incorporated right from the beginning so that they become an integral part of our lives. Behavioral modification can start from home for which the parents need to be educated, schools where teachers need to be educated to disseminate the knowledge, and then social media, the internet, government websites, and television advertisements can play an important role. At community levels, teams of volunteers can arrange nuked Natak and stage shows. Hospitals and support groups should provide educational material regarding the benefits of lifestyle modifications. 

Limitation of the Study:  This study is done in the hospital setting so the study population is not the true representative of the general population. The knowledge regarding PCOS is assessed only in female participants. Since PCOS management starts way before the appearance of the symptoms it requires a behavioral change at the community level to incorporate healthy lifestyle changes at an early age. Hence educating both males as well as the female is necessary. The sample size is also small so the findings cannot be generalized to the whole population.

Conclusion

Lifestyle modification in terms of exercise and healthy eating habits has got many benefits in a woman with PCOS. In those already diagnosed to have PCOS lifestyle modification is the first line of management. It can cause a marked improvement in the symptoms and reduce the chances of complications in those already diagnosed with PCOS. Those requiring medical management will also benefit from a continued healthy lifestyle. 

Awareness about improving lifestyle, healthy eating habits, avoiding a sedentary lifestyle from a young age will help in lowing the incidence of the disease and complications related to the disorder. 

Declarations

The Study was approved by the Institutes ethical committee with approval number IEC/11/2021.. Participation in the study was voluntary and a written informed consent was obtained from the participants after explaining them the purpose of the study.

Availability of data and materials: 

The data used and /or analysed during this study are available from the corresponding author on reasonable request. 

Authors Information:   

Affiliations:

1.Department of Obstetrics & Gynaecology, All India Institute Of Medical Sciences, Bilaspur. H.P, India

Dr.Asmita

2.Department of Obstetrics & Gynaecology, Baba Saheb Ambedkar Medical College & Hospital, New Delhi, India

Dr.Prachi Renjhen

3.Guru Teg Bahadur Hospital, New Delhi

Dr.Rajeshwari Kumari

Correspondence to : [email protected]

Contributions 

1.AK: Concept and planning of the study, preparation of questionnaire, data collection and analysis, drafting the manuscript

2.PR: Proof reading and approval of the questionnaire, data collection, proof reading and final approval of the manuscript

3.RK: Data collection, proof reading of manuscript

Consent for publication : Not applicable

Competing Interests : Authors have no competing interests.

Funding: No external funding was received

Human rights statements and informed consent : 

All procedures were performed in accordance with the ethical standards of the relevant committees on human experimentation (institutional and national) and the Helsinki Declaration of 1964 and its later amendments. Informed consent was obtained from all patients included the study. 

References

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Tables

Table I. Demographic Profile of Study Population

Variable 

N=334 

% age

Mean ± SD

Age (in years)

                          

 

  28.70±6.29

 

15-20                                 

09

2.7

21-30

205

61.4

31-40

102

30.5

41-50

18

5.4

BMI 

 

  23.61±4.54

< 18.5

45

13.5

18.5-24.9

165

49.4

25.0-29.9

96

28.7

>30.0

28

8.4

Education 

Illiterate

62

18.6

 

Primary 

27

8.1

High School 

74

22.2

Graduate 

143

42.8

Postgraduate

28

8.4

Occupation 

House wives

165

49.4

 

Working (private/Government/Self)

79

23.6

Students

90

26.95

Marital Status

Married 

206

61.7

 

Unmarried 

128

38.3

Age at Menarche

< 13 years

24

7.2

 

 13.48±1

13-15 years

271

81.1

  1. ears

31

9.3

>18 years

none

none

Cycle Length 

 

 

21.56±3.28SD 

<21 days

30

8.9

21-35 days

215

64.37

35- 60 days

78

23.35

>60 days

05

1.49

Totally invariable

06

1.79

 

Table II. Presence of Symptoms related to PCOS

S.No. 

Symptom Present

N=334(% age)

1.

Change in cycle length in previous 3 months 

 

 

Yes 

119 (35.6))

 

No 

215 (64.4)

2.

What change 

 

 

Frequent cycle 

30 (9)

 

Delayed Cycles

83 (24.8)

 

Heavy Cycles 

1 (0.3)

 

Scanty Cycles

5(1.5)

3.

Treatment taken to correct menstrual irregularity in past 3 months

 

 

Yes 

33(9.8)

 

No 

301(90.1)

4.

Change in weight in previous 3 months

 

 

Yes

25(7.5)

 

No 

307(91.9)

5.

What Change 

 

 

Weight Gain 

21(6.3)

 

Weight Loss 

4(1.2)

 

No Change 

307(91.9)

6.

Excessive hair growth on body in past 3 months

 

 

Yes 

8(2.4)

 

No 

326(97.6)

7.

Excessive hair fall

 

 

Yes 

30(9)

 

No

304(91)

8.

Acne

 

 

Yes 

29 (8.7)

 

No 

305(91.3)

9.

Are you trying to conceive 

 

 

Yes 

27(8.1)

 

No

307(91.9)

10. 

Any problems in conception 

 

 

Yes 

22 (6.6)

 

No 

312 (93.4)

11.

Taking any fertility treatment 

15(4.4)

 

Table III: Awareness regarding Symptoms, Risk Factors, complications and management of PCOS

Question 

N=334 (%age )

Heard about PCOS

 

Yes 

145 (43.4)

No 

189(56.6)

Have you been diagnosed as PCOS

 

Yes 

31(9.3)

No 

303 (90.7%)

Source of Information 

 

  1. Teacher 

19(5.6)

  1. Doctor 

89(26.6)

  1. Friend 

16(4.7)

  1. Television 

0(0)

  1. Newspaper 

0(0)

  1. Internet

21(6.28)

Symptoms: PCOS can manifest as 

 

  1. Menstrual Irregularity

142 (42.5)

  1. Hirsutism 

90 (26.9)

  1. Acne

70 (20.9)

  1. Weight gain 

119 (35.6)

  1. Difficulty in conception 

117(35.02)

  1. Abortions

115 (34.4)

  1. Hair fall

82 (24.8)

Risk Factor 

 

  1. Obesity 

112(33.5)

  1. Unhealthy eating habits 

117(35)

  1. Sedentary life style 

121(36.2)

  1. Genetic

136(40.7)

Complications 

 

  1. Infertility 

134 (40.1)

  1. Abortions

115 (34.4)

  1. Diabetes

96(28.7)

  1. Hypertension 

106(31.7)

  1. Cardiovascular Disorders

112(33.5)

  1. Endometrial Carcinoma

120 (35.9)

  1. Psychological problem, anxiety, sleep disturbances 

124(37.1)

Management 

 

  1. Avoiding junk food & Healthy eating habits

124 (37.1)

  1. Exercise and weight loss

137(41)

  1. Stress management 

119(35.6)

  1. Medications 

114 (34.1)

  1. Surgery 

96 (2.7)


Table IV. Correlation between Education System and Knowledge Score

Total Score

Education

Total

ILLITERATE

PRIMARY

HIGH SCHOOL/PUC

GRADUATE

POST GRADUATE

 

0

59(95.2%)

27(100%)

52(70.3%)

44(30.8%)

8(28.6%)

190(56.9%)

1-5

0(0%)

0(0%)

4(5.4%)

8(5.6%)

0(0%)

12(3.6%)

6-10

0(0%)

0(0%)

7(9.5%)

32(22.4%)

10(35.7%)

49(14.7%)

11-15

3(4.8%)

0(0%)

11(14.9%)

59(41.3%)

10(35.7%)

83(24.9%)

Total

62(100%)

27(100%)

74(100%)

143(100%)

28(100%)

334(100%)

Mean ± SD

0.68±3.03

0±0

2.99±4.83

7.41±5.67

7.89±5.71

4.62±5.71

P≤0.001**, Significant, Student t Test

Table V Correlation of Knowledge Score and Occupation Status of the women

Total Score

OCCUPATION

Total

HOUSEWIFE

STUDENTS

Working Women 

0

151(91.5%)

16(20.3%)

23(25.6%)

190(56.9%)

1-5

0(0%)

4(5.1%)

8(8.9%)

12(3.6%)

6-10

1(0.6%)

26(32.9%)

22(24.4%)

49(14.7%)

11-15

13(7.9%)

33(41.8%)

37(41.1%)

83(24.9%)

Total

165(100%)

79(100%)

90(100%)

334(100%)

P≤0.001**, Significant, Chi-Square Test