The Prevalence of Thyroid Dysfunction in PCOS Women in Comparison with A Control Group


 Background

One of the common disorders that affect females of reproductive age is the Poly-Cystic Ovarian Syndrome (PCOS). Thyroid dysfunction is also more prevalent in this age group. This study aimed to evaluate the prevalence of thyroid dysfunction in women with PCOS in comparison with control and to investigate the association between hypothyroidism and PCOS in women of ovulatory age.
Patients and Methods:

Eighty female subjects of fertility age were selected and divided into two equal groups. The first 40 subjects are healthy females as a control group. The second 40 group are patients with PCOS. The PCOS women were diagnosed by Rotterdam criteria and performed thyroid tests, sex hormones and lipid profile tests.
Results

The results show that PCOS women with hypothyroidism are tending have a high body mass index (BMI). Forty-five percent of PCOS patients had hypothyroidism which was investigated in TSH and T4 tests by 35% and 10%, respectively. A high level of testosterone was found in females with PCOS. The cholesterol shows a significant correlation with the alteration in Thyroid Stimulating Hormone (TSH).
Conclusion

There is a correlation between thyroid dysfunction especially hypothyroidism with the polycystic ovarian syndrome because both of them lead in features to metabolic syndrome and there is a high prevalence of hypothyroidism in women with PCOS


Introduction
One of the common endocrinal disorders is the Poly-Cystic Ovarian Syndrome (PCOS) which is also known as a syndrome of Stein and Leventhal that affect about 5 to 10 % of the female in reproductive age [1]. This disorder induces mainly a disturbance of the ministration period, hyperandrogenism, and infertility. These changes cause an increase in the risk factor of metabolic syndrome and cardiovascular disease due to increased insulin resistance and obesity [2]- [4]. The morphology of the polycystic ovary is de ned by the European Society for Human Reproduction and Embryology (ESHRE) and the American Society for Reproductive Medicine (ASRM) that convened in Rotterdam, Netherland [5]. The ESHRE/ASRM concluded three major criteria should be found to diagnose PCOS. If 2 out of these three criteria were veri ed, the female was diagnosed with PCOS. These criteria are: 1. Menstrual abnormalities like anovulation (or amenorrhea), oligomenorrhoea, or long cycle 2. Hyperandrogenism -Clinical or biochemical signs observed such as acne, hirsutism or high levels of testosterone 3. The polycystic appearance of ovaries by echographic such as ultrasound (US), containing multiple small follicles measuring from 2 to 9 mm The main dysfunction of the thyroid is an irregularity of the menstrual period and also infertility which is caused by ovulatory dysfunction. These main dysfunctions had a serious effect on the female reproductive system [6]. Thyroid disease is one of the autoimmune diseases that can be recognized when the previously main dysfunction increased. A bidirectional association between the PCOS and the thyroid has been suggested but it is still uncertain. Most studies were performed on the pathophysiological incidence, cause and clinical features of the PCOS [7].
A study performed by Diksha Goyal et. al [8], who found that the TSH in PCOS patients was higher than the healthy subjects. Furthermore, Ding et. al. [9], demonstrated that the PCOS risk increased as a result of clinical hypothyroidism and depressive symptoms such as anxiety. Also, they claimed that subclinical hypothyroidism during pregnancy could lead to multiple adverse maternal and neonatal outcomes, including premature rupture of membranes and neonatal death.
The relationship between thyroid dysfunction and polycystic ovulatory syndrome is not widely discussed by the authors especially in Iraqi patients. This study aims to evaluate the prevalence of thyroid dysfunctions in women with PCOS in comparison with the control group. Also, to evaluate the relationship between PCOS and thyroid dysfunctions (ovarian hormones and thyroid hormone).

Patients And Method
This case-control research was conducted in the department of infertility of Al-Yarmouk teaching hospital, Baghdad, Iraq. The study was approved by the physiology department committee, College of Medicine, Al-Mustansiriyah University, Baghdad, Iraq. Eighty females selected in this study according to the declaration of Helsinki and divided equally into two groups: Forty with PCOS who were diagnosed by the Rotterdam criteria 2003 [5], [10] and the other forty who are health control.
The complete history of all the subjects is assessed included the medical, surgical, menstrual. Then, a physical examination including weight and height was performed for measuring the BMI (weight in kg/(height) 2 in m 2 ). An ethical consent was obtained from the patients included in this study. Transabdominal ultrasound was done for both groups PCOS and normal women. A blood venous blood of 5 ml was collected from both PCOS and control groups of women to evaluate the thyroid function test such as TSH, T3, T4 and FSH, LH, testosterone and prolactin hormone. Also, the lipid pro le, FBS, fasting insulin level was assessed. The SPSS-24 was used for statistical analysis purposes at signi cant level ≤0.5.
-Inclusion criteria 1. Irregular menstruation for PCOS women: no menses in the past 6 months or menstrual cycle prolonged for more than 35 days. Regular manse for the control group.

Results
A comparison between the characteristics and analysis of PCOS patients and control females selected in this study are illustrated in the table (1). A signi cant difference between the PCOS and control was found in length and BMI values.
The comparative analysis of lipid pro le including the cholesterol, HDL, LDL, and VLDL. There was no signi cant difference between the PCOS and control women are shown in the results.
The comparison of glucose analysis was performed between the healthy and PCOS patients including the triglyceride (TG), fast blood sugar (FBS), and fast insulin. The statistically signi cant difference was found with FBS and fast insulin but not for TG. The clinical features such as the presence or absence of acne, hirsutism, and hair falling were investigated for both PCOS patients and control groups as presented in gure (1). It shows that 50 %of PCOS groups had acne, while it was 12.5 % for the control group. For hirsutism, a higher percentage was found for PCOS (80%) than the control group (10%). Furthermore, 90% of a female with PCOS shows to had a hair falling rather than the control who had 15% in normal condition.
We show the statistical results of sex hormones tests in the table (2) for the LH, FSH, prolactin, and testosterone. It shows a signi cant difference for LH between the PCOS and control. Where both LH and testosterone show a high level of PCOS.

Discussion
The median female age of this study is 29 and the range is within the reproductive age. The PCOS group tends to be overweight or obese with a higher BMI other than the control. The increase in BMI is maybe related to two causes, the rst one is PCOS and the second cause may be hypothyroidism. Forty-ve percent of PCOS in this study are obese. Deepa et al [6] are in coordination with these ndings. They had a mean age is 26 ± 4.2 and a BMI of 29 ± 4.4 with 32% of PCOS patients are obese. Rahul et al [11] studied the correlation of thyroid dysfunction with the PCOS prevalence and found spatially hypothyroidism increased in PCOS incidence and obese women. Mayada et. al. [12] found an increase in BMIO in PCOS women.
Women with PCOS complain of many symptoms and clinical features, such as amenorrhea, hirsutism, obesity, enlarged ovaries and infertility. It is associated with increased cardiovascular disease risk factors, such as increased blood pressure, dyslipidemia, insulin resistance, and impaired glucose tolerance [13] The clinical feature of the PCOS group of patients presented a higher incidence than the healthy women. These ndings are agreed with Deepa et al.
[6] who found out that 52% of patients suffer from these clinical features. The result in the current research agrees with their study as shown in table (2) and we noticed that there is an increase in testosterone and hormone levels in PCOS females rather than healthy women. Also, Najem et al. [14] reported that all PCOS women included in their study are shown hyperandrogenism clinical features.
When the thyroid analysis was investigated for PCOS women in this study, it appears that 45% had hypothyroidism and 35% out of them were shown in the TSH test. Sinha et. al. [15] showed that 27.5 % of the PCOS females had thyroid disorder where 22% of them suffering hypothyroidism. Furthermore, they reported that TSH levels in the PCOS group were signi cantly higher than in the control group.
Many authors studied the relationship between the metabolic analysis for PCOS women and thyroid dysfunction The diagnosis of PCOS by ultrasound (US) is not precise and dependable. Further investigations need to be performed in order to gain an accurate diagnosis. We should mention that when hypothyroidism affects PCOS women, it worsens their symptoms by lowering the level of binding globulin belongs to sex hormone, which converts the androstenedione into testosterone and aromatization to estradiol. Also, it reduces the metabolic clearance rates of androstenedione and estrone [22], [23].

Conclusion
In conclusion, the prevalence of thyroid dysfunctions, especially hypothyroidism, is increased in women with PCOS patients. There is an association between polycystic and hypothyroidism in metabolic conditions. For accurate diagnosing, lipid pro le and thyroid function should be performed for PCOS patients.

Declarations
All manuscripts must contain the following sections under the heading 'Declarations': Clinical features of PCOS patients and control