“Clinical subjects. Objective: 1) To find out pattern

 “ClinicalManifestation of Polycystic Ovarian syndrome & it’s relationship withPsychological Distress Levels among the concerned subjects  in Allahabad City”.

 AbstractPolycysticOvarian Syndrome is a complex endocrinopathy affecting women of reproductiveage affecting  5 to 10 % populationworldwide. In India, it has been reported that 9.13 to 22.5 % population aresuffering from this syndrome, but prevalence rate varies with different regionsof the country. Likewise, vast difference has also been reported in clinicalmanifestation of PCOS. It is increasingly recognised that ethnic differencesare likely contributors to the differing manifestations of PCOS. It is nowaccepted that this problem is arising from persistent anovulation with aspectrum of etiologies and clinical manifestations. However, there has beenvery limited research data available in India regarding pattern of clinicalmanifestation of PCOS and most of the research studies done in South India.

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Ithas also been reported in previous studies that PCOS affects quality of lifeand can worsen existing anxiety and depression either due to the features ofPCOS  or associated comorbidities. Hence, it seems necessary to find outthe pattern of clinical manifestation of PCOS and it’s relationship withPsychological Distress levels among PCOS subjects. Objective: 1) Tofind out pattern of clinical manifestation of PCOS in Allahabad city.2) To findout the association between Clinical Manifestation and Psychological Distresslevels among PCOS sufferers.

Materials& Methods: In this cross-sectional, descriptive study, 200 patientswith PCOS were recruited from various Hospitals & Nursing Homes ofAllahabad city. A self made questionnaire with items related to pieces of informationabout clinical symptoms was used for data collection. Psychological Distresslevels were assessed using the P.

G.I Health Questionaire N1. Statisticalanalyses were performed using SPSS Ver. 20.

0. Chi Square test was used to testthe association between variables. A p-value less than 0.05 was considered asstatistically significant.

Results: Thefindings of the study revealed that PCOS subjects having more clinicalmanifestation were moderate to severe neurotic. The most common phenotypic expressionfound to be was Androgenic Alopecia followed by Hirsuitism however, mild tomoderate level hirsuitism was found in patients, severe hirsuitism cases wererare which is believed to be a most common clinical symptom found in Asiancountries as compared to Western countries.After that Duration Between Menses,Acanthosis Nigricans, Insomnia, Acne Vulgaris, Sleep Apnea and infertility in asequence was reported. Infertility present in most of the married subjects butmost of the subjects having children with PCOS were also found moderate tosevere neurotic. Conclusion: The researchstudy revealed that most of the PCOS subjects having different clinicalmanifestation comes under moderate to severe neuroticism .

Keywords: Endocrinopathy, Anovulation, Hirsuitism, AcanthosisNigricans, Acne Vulgaris, Androgenic alopecia    INTRODUCTION Polycystic Ovarian Syndrome is characterized by multiplephenotypes i.e clinical symptoms which varies with ethnic origin. Globally,prevalence estimates of PCOS are highly variable, ranging from 2.

2% to as highas 26%. The differences in phenotype and clinical symptoms of PCOS related tothe clinical, hormonal, and metabolic characteristics among various ethnicbackgrounds, including Hispanics, African Americans, Asians, and Indians, needto be considered when assessing and treating these individuals. Accordingto Times of India survey (15 May,2017)it was found that eastern part of India showed a higher percentage of women(25.88 per cent) affected by PCOS. The figure was 18.62 per cent in north Indiaand 18 per cent in south India. India is a country of cultural variation andthe figures of survey itself explains the ethnic variation behind clinicalmanifestation of the PCOS.

AIMS/OBJECTIVE: Ø Tofind out the pattern of clinical manifestation among population havingPolycystic Ovarian Syndrome in Allahabad City.Ø Tofind out the relationship between clinical manifestation of Polycystic OvarianSyndrome and Psychological Distress levels among concerned population.METHODOLOGY: The research study was non comparative, cross-sectional, descriptive& hospital based survey. In this Study, purposive sampling was done on thebasis of Rotterdam criteria to get Polycystic Ovarian Syndrome patients, afterthat age based stratification was done to get 200 patients of 18-48 years ofage group from various Hospitals, Nursing Homes of Allahabad city. Patientssuffering from serious metabolic disease had been excluded from the study. Aself made questionnaire with items related to pieces of information aboutclinical symptoms was used for data collection. Psychological Distress levelswere assessed using the P.G.

I Health Questionaire N1. Statistical analyses wereperformed using SPSS Ver. 20.0. Chi Square test was used to test theassociation between variables.

A p-value less than 0.05 was considered asstatistically significant.         RESULT & DISCUSSION/FINDINGSThe presentstudy was carried out at Nursing Homes, Hospitals and community in AllahabadCity. The findings of the study arefollowing:Ø  Table:1 Most Common ClinicalManifestation of PCOS    CLINICAL SYMPTOMS   PARAMETERS   FREQUENCY       (N)   PERCENTAGE             (%) Androgenic Alopecia        Present                                                    Absent Hirsuitism                        Present                                         Absent   Duration between            Menses                                  Acanthosis Nigricans      Present                                        Absent Insomnia                       Present                                       Absent   Acne Vulgaris               Present                                     Absent     Sleep Apnea                  Present                                     Absent Infertility                      Present                                     Absent                           *Not Applicable (*NA=Unmarried girls)     – – Mild Moderate Severe   <21 Days 21-34 Days (Normal) 35-60 Days >199 Days         <7 hours sleep >7 hours sleep       152 48 90 52 4 54 52 83   32 33   97 103 76 124   67 133              59 141 50 57 93 76 24 45 26 2 27 26 41   16 16   48.5 51.

5 38 62                         33.5 66.5   29.5 70.5 25 28.5 46.5  v  Androgenic alopecia was reported in 155 patients out of200,(about 77.5 % population) and it was reported to be the most commonclinical symptom of PCOS which is then followed by hirsuitism among 71 %population, duration between menses among 60 % population, acanthosis nigricansamong 51 % population, insomnia among 36% population, acne vulgaris among 33.

5% population, sleep apnea among 27.5 % population, infertility among 25 %population were reported. However, the findings is in contrast with previousresearch finding done in North India by Abidet al., 2017 who rankedandrogenic alopecia in third place about 31 % after hirsuitism and acne vulgaris.According to Quinn et al.,2014 Androgenic alopecia is prevalent in 22% of subjectsmeeting diagnostic criteria for PCOS.

v  Mild to Moderatelevel Hirsuitism was reported among PCOS Sufferers while severe cases ofhirsuitism were rare. This finding is in contrast with the previous researchfinding of Philip etal.,2014 who revealed that Hirsuitism being a more prevalent symptom ofhyperandrogenism in women from the Indian subcontinentand from Mediterranean countries thanit is in those of northern European oreast Asian origin. In our study, hirsuitism ranked in second place afterandrogenic alopecia while accordingto previous study by Abid et al., 2017  the prevalence of hirsutism was reported tobe 78 % and he ranked it in first place to be the most common clinical symptom.v  In most of the cases about 41 %, duration between menses wasreported to be in normal range, after that in 26 % cases, menses duration wasreported to be less than 21 days while 16 % population suffered from menstrualdelay of more than 199 days and about rest of 16 % population suffered frommenstrual delay of 35-60 days.

Oligomenorrheoa was present in 32 % patients.However, hypomennorhea was reported in major population. In the present studyall patients complained of irregular menses while mennorhagia was reported in26% cases which is also reported by Maslyanskayaet al.

,2017 who revealed thatPCOS was the most common etiology seen in adolescent patients hospitalized forabnormal uterine bleeding. However in our study, it has been observed that menstrualdelay among major population comes within normal range. Hence it has beenrevealed that although menstrual duration remains regular, hypomennorhea comesout to be a better predictor of PCOS.

However, most of the population believedregular menstrual cycle to be a better predictor of menstrual health, while inmost of the cases, menstrual bleeding shifted from 5 days to 3 days and evenless in some cases. v  AN is a velvety,mossy, hyper pigmented skin disorder. Presence of AN appears to be more a signof insulin resistance than distinct disease itself. Acanthosis Nigricanswas reported in 48.5% subjects and got fourth place in a sequence whileaccording to Abid et al.,2017 it has been observed in 30 % population but heranked it too at the fourth place. Thefinding of study is concordant with the previous study by Sunita et al.

,2013, whorevealed that 44.16% patients showed presence of AN, a surrogate marker ofinsulin resistance.v  Insomnia wasreported in 38 % population.According to Franiket al.

,2016, clinicallysignificant insomnia according to both AIS and ISI, occurred significantly moreoften in women with PCOS than in women without PCOS.v  In our study, Acnevulgaris was reported in 33.5 % population while about 48 % population werehaving this symptom according to Abid etal., 2017  who ranked it second most common symptomafter hirsuitism.

v  Sleep Apnea was reported in 29.5 %population. According to Vgontzas etal.,2001, the risk for Obstructive Sleep Apnea is at least5-fold higher, and perhaps as much as thirty-fold higher in PCOS, than insimilarly obese women.v  In presentstudy, it has been revealed that 25 % population were suffering frominfertility at the time of survey. Although PCOS is believed to be one of thebiggest cause behind Infertility but in our study, some of the population wereeither having children with PCOS or they were unmarried at the time of surveywhile about 2-17 years of infertility had been reported among married subjects.However, Sunita et al.

,2013 revealed that about 44.68% married PCOS womencomplained of infertility.                         Ø  Table:2 Relationship betweenPsychological Distress Level & Clincal Symptoms of PCOS in ConcernedSubjects      CLINICAL SYMPTOMS         PARAMETER     MILD NEUROTIC       MODERATE NEUROTIC     SEVERE NEUROTIC     P VALUE    Androgenic Alopecia   Hirsuitism       Duration between Menses     Acanthosis Nigricans   Insomnia   Acne Vulgaris Sleep Apnea       Infertility                    Present       Absent Mild Moderate Severe Absent < 21 Days 21-34 Days 35-60 Days >199 Days Present Absent Present Absent Present Absent Present Absent    Present Absent *Not Applicable (Unmarried Girls )   3 0 3 0 0 0 3 0 0 0 3 0 0 3 0 3 0 3   0 0 3   45 13 15 14 0 29 16 32 3 7 32 26 7 51 24 34 14 44   19 20 19   104 29 72 35 4 22 30 51 26 26 62 71 66 67 43 90 45 88   28 31 71            P >.

05 Not Significant   P < .05 Significant   P < .05 Significant     P > .05 Not Significant P < .05 Significant P > .05 Not Significant P > .05 Not Significant   P < .

05 Significant  There has beensignificant difference found in four clinical symptoms while non significancehas been reported in rest of the four symptoms. According to the data, most ofthe severe neurotic population were found sufferers of Androgenic alopecia toobut non significant result has been reported on Chi square test. Multiplefactors may be responsible for such outcome as some other confounding factorsmay be involved behind hair falling like micronutrient deficiency, heredity,etc. It is difficult to search out the exact reason behind androgenic alopecia.While in rest of the non significant results, difference between factors werenot found considerable as acanthosis nigricans was reported in about 62 severeneurotic subjects while absent in 71 subjects. Likewise, sleep apnea was reported in only 45 severe neuroticsubjects while absent in 88 severe neurotic subjects while acne vulgaris whichis believed to be one of the most common symptom, has not been reported in 90severe neurotic subjects while present in only 43 subjects.

Here we canunderstand that above clinical symptoms has no association with psychologicaldistress levels. However out of four significant results, hirsuitism has beenwitnessed in major population however only mild to moderate level hirsuitismhas been reported among severe neurotic patients while only four severeneurotic subjects comes under severe hirsuitism cases. Most of the populationsuffering from Oligomennorhea, mennorhagia and rest of the subjects havingalmost normal menses comes under severe neurosis. Hence, it is very difficultto find out the severity of PCOS on the basis of Psychological well being asalmost similar level of neurosis has been witnessed among the concernedpopulation. Likewise, Insomnia has been reported in 66 severe neurotic patientsand absent in 67 severe neurotic subjects.

According to the data, Insomnia hasnot been reported among major population. Although, irregular sleep has beenreported in major population. Along with it, many of them admitted that theypreferred day time sleeping.

Infertility was reported among 28 severe neuroticand 19 moderate neurotic subjects while absent in 31 severe neurotic and 20moderate neurotic subjects, while majority of unmarried girls were found severeneurotic. Although, PCOS is believed to be one of the biggest cause ofinfertility, but in our study, some of the population were either havingchildren with PCOS or they were unmarried at the time of survey while about2-17 years of infertility had been reported among married subjects. However inour study, it has been reported that most of the married population were havingchildren with PCOS but they were suffering from severe neurosis too.

Thus, wecan conclude that major population comes under moderate to severe neuroticism,although they were having wide variation in clinical manifestation or we cansay that no significant association has been reported between Clinical Manifestationand Psychological Distress levels of PCOS subjects as far as present study isconcerned. CONCLUSION India is acountry of cultural variation and diversities which leads to proliferation ofdifferent ethnic groups across the country. It is increasingly recognised thatethnic differences are likely contributors to the differing manifestations ofPCOS.  Although very limited studies havedone on the concerned issue in India. Wijeyaratneet al.

,2002identified a younger age of presentation with oligomenorrhoea, increasedhirsutism, acne, acanthosis nigricans and infertility in South Asian women fromthe Indian subcontinent with PCOS as compared with Caucasian women with PCOS. Onthe basis of previous studies, it has been found that ethnic factors likedietary pattern, lifestyle pattern, race, social beliefs has strong associationwith clinical manifestation of PCOS. The present study was carried outin Allahabad city where most of the population belongs to North India andhaving similar eating and lifestyle pattern.

In our study, clinicalmanifestation of PCOS was found to be much varied than previous studies.  In our study, the most common phenotypic expression found to be was AndrogenicAlopecia followed by Hirsuitism. However, only mild to moderate level hirsuitism was found in patients whilesevere hirsuitism cases were rare, which is believed to be a most commonclinical symptom found in some Asian countries including India as compared toWestern countries.

After that Oligomennorhoea was reported which is thenfollowed by Acanthosis Nigricans, Insomnia, Acne, Sleep Apnea, Infertility in asequence. Major population of PCOSwere moderate to severe neurotic. The present study revealed that there hasbeen lots of variation in clinical manifestation of PCOS in India itself.Alongwith it, psychological distress level of subjects  having most of the clinical symptoms has beenrevealed. However, larger studies may have the power to detect the variation inpattern of clinical manifestation and relationship between the variables.



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