This cross-sectional study was conducted on a group of PCOS women who referred to the gynecological clinics of hospitals in Tehran province (Iran) between May 2018 and February 2019 through the convenience sampling method. The Ethics Committee of Tarbiat Modares University of Medical Sciences approved the study protocol (IR.MODARES.REC. 1397.211).
Firstly, sample size was calculated using the appropriate formula and considering the 95% confidence interval. Consequently, 364 women with PCOS diagnosis according to the Rotterdam criteria (95 women with phenotype A, 78 women with phenotype B, 95 women with phenotype c and 95 women with phenotype D) were recruited after obtaining a written consent. Eligibility criteria required for selecting the subjects were as follows: married women of reproductive age (18-45 years) who lived with a husband and were sexually active (had sexual intercourse in the past four weeks). In addition, PCOS was diagnosed based on the Rotterdam criteria and willing to participate in this study. The possible confounding factors were avoided by the exclusion criteria: pregnancy, breastfeeding, suffering from endocrine and chronic diseases (like diabetes, cardiovascular diseases, kidney disease, benign and malignant tumors, etc.), taking any hormonal and herbal medicines in the last month due to their possible impact on SF and androgen levels. The participants were asked to fill out the questionnaires, which included a series of questions about demographic characteristics and sexual dysfunction.
Anthropometric measurements including weight, height, hip circumference (HC), and waist circumference (WC) were measured by the same person for all participants. Body mass index (BMI) was calculated based on dividing weight in kilogram by square of height in meter for assessing the obesity (10). Additionally, WC was measured at the narrowest point between the lower rib and iliac crest in the standing position and HC was calculated at the widest part of the buttocks, dividing WC by the HC was considered as the Waist to Hip Ratio (WHR) (11).
Clinical and para-clinical features
Clinical features such as hirsutism, menstrual cycle status, and acne were assessed by a clinician. Menstrual cycle lengths shorter than 24 days and longer than 34 days were considered abnormal. The modified Ferriman–Gallwey (mFG) was used to identify hirsutism. It consists of observing the quantity and distribution of terminal hair in nine body areas, including the upper lip, chin, chest, upper and lower abdomen, back, sacroiliac region, thighs, and arms. These areas were given a score ranging from 0 to 4 according to quantity and density, with higher scores indicating a greater amount of body hair (12). The reliability and validity of this questionnaire have been confirmed in Iran (13).
The degree of severity of acne was examined based on the Conference on Acne Classification, which is divided into mild, moderate and severe. The mild form consists of small comedowns’ number of papules and nodules, with no cysts and scars. Although there are very large number of papules and posture in the medium form of acne, nodules, cysts and scars are seen rarely. In the severe form, the number of papules and pustules is very large and the number of nodules, cysts and scars is also high (14).
Polycystic ovary morphology (PCOM) was detected based on the Rotterdam PCOS criteria: An ovarian volume >10 mL or containing 12 or more follicles (2–9 mm) in size was distinguished as a positive PCOM.
All blood samples which contained LH, FSH, Testosterone, SHBG, TSH, progesterone and prolactin were measured on day-3 of the menstrual cycle by the same laboratory tests (ELISA method). Also the Free Androgen Index (FAI) value was calculated by dividing the total testosterone (nmol/lit)/SHBG multiplied × 100.
A socio-demographic questionnaire (including age, marital status, employment status, educational level, BMI, history of chronic disease, menstrual and reproductive history such as duration and length of the menstrual cycle, regularity of cycle, number of children and abortion) was completed.
To assess SF, all participants were asked to fill out Female Sexual Function Index (FSFI), which includes 19 questions to measure women's SF in six areas: desire, arousal, moisture, orgasm, satisfaction and pain. Evaluation was done through the Likert scale. Total score was obtained by summing the six domain scores. A higher score is associated with a lower degree of sexual dysfunction and the total score of 26.55 is the optimal cut score for differentiating women with and without sexual dysfunction (15). The reliability and validity of this questionnaire have been confirmed in Iran (16).
Statistical analysis was performed by using the SPSS software (ver. 16). The normality of data was assessed using the Kolmogorov-Smirnov's test and presented as mean+SD for normal and quantitative data. A one-way ANOVA was used with Tokay, and Post Hoc test to compare normal variables between the groups, and Kruskal-Wallis test was used to compare non-normal variables between different phenotype groups. The Mann-Whitney’s U test (MW) was performed for pairwise comparison of the groups. Also, to compare qualitative variables between the different groups, Chi-square test, and Fisher's exact test, Fisher's generalized test were used. P-values lower than 0.05 were considered statistically significant.