Health Awareness of Polycystic Ovarian Syndrome and Its Complications in Lebanon: A Cross-sectional Study

Background: Polycystic Ovarian Syndrome (PCOS) is a common disorder that has many different presentations in females. However, females with this disorder, and due to their lack of awareness, usually have delayed diagnosis and treatment. The objective of this study is to assess knowledge about PCOS amongst Lebanese women in the reproductive age group. Methods: Cross sectional study was performed on 421 women of age group 18-51 years from all governorates in Lebanon. Written informed consent and participants were included through the help of convenient sampling. A well-conducted questionnaire was constructed and the study was approved by the Institutional Review Board’s Committee at Beirut Arab University (BAU) prior to data collection. Data entry was completed with SPSS (IBM version 23.1) and analyzed descriptive measurements like mean and standard deviation were used for quantitative variables, whereas percentages were used for qualitative variables. Frequencies were assessed for categorical variables. Chi-Square test and P-values, were used to compare between qualitative variables. Results: Among 421 participants, 75% were aware of the term PCOS. More than 60% knew about the various signs and symptoms associated with PCOS but around half were aware about its complications. Around two-third agreed that exercise was one of the methods that could alleviate PCOS symptoms, and around 57% agreed that weight loss could decrease symptoms as well. Conclusions: The results of the present study show that Lebanese women were aware of common symptoms of PCOS. On the other hand, their knowledge was minimal regarding more complex manifestations and complications of PCOS.

those with polycystic ovary syndrome had a higher risk of developing coronary-artery calci cation than their counterparts (10). Increased levels of plasminogen-activator inhibitor type 1 may contribute to the development of cardiovascular diseases and anovulation, a conclusion found by a study in the United Kingdom (11). Another United Kingdom study revealed that PCOS could lead to endometrial, breast and ovarian cancers (12). A study done in Sweden showed that PCOS is strongly associated with the development of psychiatric and eating disorders (13). Furthermore, a study conducted in Chicago has documented that PCOS and obstructive sleep apnea (OSA) are related (14).
Several studies were done worldwide concerning knowledge, awareness and perception of female participants about PCOS. A study was conducted in Central India showing that among 400 participants, only 40% of the women were aware of PCOS; concluding that very few of the young women understood the nature of the disease (15). Another study done among female science students of different public universities in Quetta, Pakistan and concluded that that the prevalence of signs and symptoms of PCOS are increasing yet students were not aware of polycystic ovary syndrome (16). Therefore, the studies conducted re ected the lack of knowledge and awareness amongst women regarding PCOS, despite its relatively high prevalence and its major medical consequences. There was a gap of literature noted and lack of studies in Lebanon on the awareness of Lebanese women regarding polycystic ovary syndrome and its complications, which led the conduction of this research project. Thus, this research aims to assess knowledge about PCOS amongst Lebanese women in the reproductive age group.

Methods:
This descriptive population-based cross-sectional study gathered surveys from female participants from all governorates in Lebanon between June 2019 and September of 2019. The study's inclusion criteria involved only competent Lebanese women, who were in their reproductive age group, ages ranging between 18 and 51 years. The surveys were collected from women living in all Lebanese governorate. Based on the number of population residing in each governorate in Lebanon, according percentages were taken from those areas. Samples were obtained, through the help of convenient sampling, from different public settings, including shopping malls, universities, parks, and as by-passers in a crowded street, where a total of 421 randomly selected participants completed the survey. This sample size was calculated based on a power of 80%, a 95% con dence level, 5% margin of error, and the population size of women in Lebanon which was estimated to be around four million giving our sample size an average size of 420 women. A survey, well developed by competent Endocrinologists in Lebanon, was utilized, and included questions regarding basic demographic data about the participants, assessment of applicants' knowledge regarding different aspects of PCOS, like its symptoms, risk factors, complications, diagnostic methods, and management approaches. Data entry was completed with SPSS (IBM version 23.1), using built range checks with automatic error prompts. Data analysis used descriptive measurements like mean and standard deviation for quantitative variables such as number of children. On the other hand, percentages were used for qualitative variables, such as whether candidates worked in the medical eld or not. Frequencies were assessed for categorical variables. Chi-Square test and P-values, were used to compare between qualitative variables.

Results:
Four hundred and twenty one female participants took part in our study. The mean age of these women was 30 years ± 9 years. Out of 421 participants, around 76% were found to have reached at least university level education, and 82% were not involved in the medical eld. Participants were collected from all governorates of Lebanon. Half of the women were employed and around 40% were married. Table 1 has the detailed basic demographic data of the participants. Awareness about polycystic ovary syndrome was assessed in this study. When asked if they have ever heard of PCOS, 75% of women answered that they have heard this term before. Moreover, 77% thought that PCOS was considered a manageable disease, and 44% answered that they thought it was acquired.
When looking into participants' awareness about symptoms and complications associated with polycystic ovary syndrome, 46% of women thought that PCOS could actually lead to miscarriages, and a signi cant percentage thought that PCOS could lead to menstrual irregularities. However, around 50% thought that PCOS could lead to increased facial acne, while 65% thought it affected fertility. More than half of women thought that PCOS lead to weight gain, however, 64% didn't know if it led to insulin resistance or not. Seventy-eight percent thought that regulating the menstrual cycle would help in regulating ovulation. More than half of the participants thought that PCOS led to hirsutism, but only 21% thought it could lead to alopecia/hair loss. Table 2 has detailed information on awareness of participants about PCOS symptoms and its complications. When asked about the complications of PCOS, 53% of women did not know if PCOS led to cardiovascular disease. However, more than half of the study population thought that PCOS could lead to an increased risk for developing uterine/breast cancers. Around 75% thought that PCOS led to increased risk of developing anxiety disorders, and 60% thought that PCOS increased the risk of developing psychological disorders. Table 3 has the detailed information about the misperceptions of female participants regarding PCOS.  Correlations were assessed between educational level and awareness of different aspects of polycystic ovary syndrome. It was also assessed whether being involved in the medical eld or not had an effect on awareness about PCOS symptoms and complications. Our results revealed that the awareness that PCOS led to abnormal ovulation was particularly high, and was speci cally thought so among University graduates. This portion of the population was also highly aware of the fact that PCOS affected fertility as well, despite the lack of evidence of a correlation between this variable and education level (p = 0.099). No signi cant association was found between education level and association of PCOS with weight gain (p = 0.072), as well as with insulin resistance (p = 0.437).
Associations seemed to exist between being in the medical eld and awareness about PCOS symptoms and complications. Around 78% of those in the medical eld thought that PCOS led to abnormal ovulation, as compared to 60 % of those not in the medical eld believing so; and a signi cant p value was noted (p = 0.049). Eighty-two percent of medical eld participants believed that PCOS may affect fertility as compared to 60% of those not in the medical eld believing so, and this again showed statistical signi cance with a p-value of 0.008. Signi cant association existed between being in the medical eld and knowing that PCOS leads to insulin resistance. No signi cant association was noted between being in the medical eld and knowing PCOS led to weight gain (p = 0.399). Table 5 lists details on association between education and PCOS awareness and Table 6 list the association between being in the medical eld and PCOS awareness.  Among those who have heard of PCOS, 17% were diagnosed with polycystic ovary syndrome. As expected the majority of women who heard about PCOS before were aware about the symptoms associated with this disorder. A strong association was found between having heard about PCOS before, and knowing it leads to irregular menses (p < 0.001). A similar association also exists between having heard about PCOS and knowing it leads to abnormal ovulation, affects fertility, causes acne, weight gain, leads to insulin resistance, increases testosterone levels, causes alopecia and hirsutism, pelvic pain and increases the risk for developing anxiety and depression (p-values < 0.001).
Only one-third of those who have PCOS thought it leads to miscarriages (p = 0.125). Similarly, no correlation exists between having PCOS and knowing it increases the risk of cardiovascular diseases (p = 0.280). This is also true for knowing it increases the risk for developing uterine/breast cancer, where only 57% of patients with PCOS thought that it did so (p = 0.701). There is also no signi cant correlation between having PCOS and knowing it increases the risk of anxiety (p = 0.895).
Check Fig. 1 Bar Chart for more information about the correlations between having heard of PCOS and knowing its symptoms and complications.

Discussion:
The study was conducted to assess awareness about PCOS amongst Lebanese women in the reproductive age group. The majority of our participants have heard about PCOS before, as compared to a study conducted in India consisting of 400 participants, where only 40% of the women were aware of the term PCOS. This generally re ects that Lebanese women know relatively well about the existence of this disease. Only 43.9% of our population regarded PCOS as an acquired disease while 20% thought it was hereditary, re ecting that Lebanese women have a poor conception of the risk factors/pathogenicity of the disease. The rest answered that they did not know if it was acquired/hereditary. PCOS is in fact a result of both environmental and genetic factors. Although environmental factors like obesity, smoking, and sedentary lifestyle all play a major role in the development of the disease, a genetic susceptibility due to family history is a key feature as well. Similarly, less than half of the study population thought PCOS led to miscarriages. The reality is that, women with PCOS are three times as likely to have a miscarriage in the early months of pregnancy as their normal counterparts 17 .
More than 80% of the population knew that PCOS led to irregular menstrual cycles, which is considered comparable to other studies assessing the same variables. One study conducted in South Australia 18, 19 , revealed that out of 57 PCOS patients, 86% of them also thought that PCOS led to irregular menses, and out of 105 primary care physicians, 90% answered the same. Yet, this value is still considered lower compared to a study conducted in the United States which revealed that almost 100% of the population thought irregular menses was one of the key clinical criteria to diagnose PCOS. Moreover, as compared to the Australian study, where only 38% of their population sample thought that PCOS decreased fertility rates, and an Indian study where 63.5% of their study population did not know that PCOS was one of the major causes of infertility among females; an impressive 68% of our population thought it was a major contributor to decreased fertility. Similarly, a greater proportion of women (56%) in our study thought PCOS increased the risk for weight gain, as compared to the Australian study where only 34% did. Regarding body hair growth patterns, more than half of our population thought PCOS led to hirsutism, as compared to the study conducted in South Australia, where only 32% of the study population thought that it leads to hirsutism. However, almost 95% of women in the American study thought hirsutism was a symptom of PCOS. On the other hand, when asked about hair loss from the head, only 20% of our population answered that it led to alopecia. It is important to note that PCOS in fact leads to hirsutism but it also leads to head hair loss, where in females it is usually abundantly present. So, while women do know it leads to hirsutism, they don't recognize that it also causes head hair loss as well.
When assessing the complications of PCOS, only 19.5% of our population thought it led to increased risk for cardiovascular diseases, as compared to an American study where approximately 70% of the population thought it did. Also, almost 98% of women in the latter study, and 72% in a Saudi Arabian study, viewed exercise and dieting as a method to decrease symptoms in PCOS, whereas only 57% regarded so in our study. 20,21 Amongst other variables assessed in our study were the risk of developing various cancers and psychological disorders in PCOS patients. However, they were not assessed in other studies to be able to compare with.
Despite the fact that the number of women in our study who have PCOS was minimal, it was found that their awareness was not signi cantly different from those who did not have the disease, and this was unexpected. This may be due to minimal guidance provided by the healthcare system regarding their disease, or due to the small population of patients in our study who actually have the disease. Maybe in future studies, awareness about PCOS could be assessed in PCOS patients only.
Limitations to our study were mainly due to political circumstances in Lebanon during the fall of 2019, and to ensure safety of our team members. Limitations included that the participants were selected by convenient sampling. Other limitations may include that participants who said they have PCOS might not have been clinically diagnosed as so, and may have self-diagnosed themselves based on common symptoms. The opposite may be true for women who might have experienced clinical symptoms but have not received a rm diagnosis for PCOS and thus identi ed as not having the disease whilst having it.

Conclusion:
The aim of our study was to assess awareness amongst Lebanese women regarding PCOS, having hypothesized they knew very little. Overall, it was found that Lebanese women were aware of common symptoms of PCOS like irregular menses and hirsutism. On the other hand, their knowledge was minimal regarding more complex manifestations of PCOS like insulin resistance and developing cardiovascular diseases. Awareness levels were more prominent in university graduates... In conclusion, Lebanese women are aware about certain aspects about PCOS, however their general knowledge is still considered weak as compared to other countries. Campaigns and more detailed explanations by physicians to PCOS patients in the future, are important in raising awareness about PCOS amongst Lebanese women.

Declarations:
Ethics approval and consent to participate: Our questionnaire was approved by the Institutional Review Board's Committee at Beirut Arab University (BAU) prior to data collection. In addition, women were informed about the aim of the study before lling out surveys, and were asked to sign the consent form on the front page of the survey pre-hand. In addition, participants were told that they had the right to withdraw at any time during the study.

Consent for publication:
Written informed consent was obtained from all participants prior to their participation.

Availability of data and materials
All data generated or analyzed during this study are included in this published article. Correlations between having heard of PCOS and knowing its symptoms and complications