Prevalence and characteristics of women with polycystic ovary syndrome in Bangladesh – A narrative review

A B. M. Kamrul-Hasan; Fatema Tuz Zahura Aalpona; Marufa Mustari; Shahjada Selim

doi:10.4103/bjem.bjem_14_22

REVIEW ARTICLE

Year : 2023 | Volume : 2 | Issue : 1 | Page : 20-28

Prevalence and characteristics of women with polycystic ovary syndrome in Bangladesh – A narrative review

A B. M. Kamrul-Hasan¹, Fatema Tuz Zahura Aalpona², Marufa Mustari³, Shahjada Selim³
¹ Department of Endocrinology, Mymensingh Medical College, Mymensingh, Bangladesh
² Department of Gyne and Obs, Mymensingh Medical College Hospital, Mymensingh, Bangladesh
³ Department of Endocrinology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh

Date of Submission	08-Oct-2022
Date of Acceptance	11-Dec-2022
Date of Web Publication	05-Jan-2023

Correspondence Address:
A B. M. Kamrul-Hasan
Department of Endocrinology, Mymensingh Medical College, Charpara, Mymensingh 2206
Bangladesh

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/bjem.bjem_14_22

Abstract

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy affecting reproductive-aged women. PCOS is not a homogeneous disease and can manifest as a range of multifaceted problems, including various reproductive, cosmetic, cardiometabolic, and psychiatric conditions. In Bangladesh, research defining the prevalence and characteristics of PCOS is not ample. This review summarizes the findings from published studies that provide consistent evidence on the prevalence and characteristics of women with PCOS in the country. The small-scale studies conducted among different subgroups of women indicate a high prevalence of the condition. Clinical presentations of PCOS in Bangladeshi women are also highly variable. A substantial portion has obesity, insulin resistance, abnormal glucose tolerance, dyslipidemia, and metabolic syndrome, which significantly threaten their cardiovascular health. Many of them have co-existent other endocrinopathies, including thyroid abnormalities. Moreover, highly prevalent psychiatric comorbidities among these women warrant routine screening for these conditions.

Keywords: Polycystic ovary syndrome, prevalence, glucose intolerance, metabolic syndrome, thyroid dysfunction, depression

How to cite this article:
Kamrul-Hasan A B, Aalpona FT, Mustari M, Selim S. Prevalence and characteristics of women with polycystic ovary syndrome in Bangladesh – A narrative review. Bangladesh J Endocrinol Metab 2023;2:20-8

How to cite this URL:
Kamrul-Hasan A B, Aalpona FT, Mustari M, Selim S. Prevalence and characteristics of women with polycystic ovary syndrome in Bangladesh – A narrative review. Bangladesh J Endocrinol Metab [serial online] 2023 [cited 2023 Mar 29];2:20-8. Available from: https://www.bjem.org/text.asp?2023/2/1/20/367277

Introduction

Worldwide, polycystic ovary syndrome (PCOS) is a common condition in reproductive-aged women and probably the most common endocrinopathy in the age group.^[1] The reported overall prevalence of PCOS according to diagnostic criteria of the National Institutes of Health (NIH), Rotterdam, and the Androgen Excess and PCOS Society is 6%, 10%, and 10%, respectively.^[2] Moreover, a vast majority of affected women (up to 70%) remain undiagnosed.^[3] The Rotterdam criteria are most widely used to define PCOS and include the presence of two of three of the following: oligo/anovulation, polycystic ovaries, and clinical or biochemical hyperandrogenism.^[4] Women with PCOS present with diverse clinical features, including reproductive (irregular menstrual cycles, infertility, and pregnancy complications), cosmetic (hirsutism, acne, baldness), metabolic (obesity, insulin resistance [IR], metabolic syndrome, prediabetes, type 2 diabetes mellitus, and cardiovascular risk factors), and psychological (anxiety, depression, body image, psychosexual disorders) features.^[1],[5] Presentation greatly varies by ethnicity, and in high-risk populations such as South Asian and Indigenous women, prevalence and complications are higher. PCOS is a lifelong disease that begins with menstrual irregularities with or without hirsutism in adolescents and ends as cardiovascular disease in later life.^[6]

Given the substantial number of women who suffer from PCOS and its significant impact on the patients and their families, a better understanding of the current burden and clinical characteristics are essential. However, most epidemiological studies on PCOS have been conducted in developed countries, with only limited information available on the burden in other parts of the world.^[7],[8] Meanwhile, few data on the epidemiology and clinical, metabolic, and endocrine aspects of PCOS in Bangladeshi women are available. This article aimed to review the literature on the epidemiology and characteristics of Bangladeshi women with PCOS.

Methodology

A detailed literature search was conducted utilizing PubMed and Google search engines using the keywords “polycystic ovary syndrome,” “polycystic ovarian syndrome,” “polycystic ovarian disease,” “PCOS,” “PCOD,” and “Bangladesh.” All review articles and original studies describing the epidemiology and characteristics of subjects with PCOS were appraised in synthesizing this review.

Prevalence of Polycystic Ovary Syndrome in Bangladesh

Eight studies searched for the prevalence of PCOS in the country; all but one study was single centered [Table 1].^{[9],[10],[11],[12],[13],[14],[15],[16]} Most of these studies were conducted among infertile women; one was conducted among hirsute women, and another among those presented with acne. Three studies used revised Rotterdam criteria for PCOS diagnosis, while the other five did not mention the diagnostic criteria used. The prevalence of PCOS ranged from 6.11% (among the subjects visiting the gynecology outpatient department) to 92.16% (in subjects consulted for hirsutism). The prevalence was 29.9%–46.15% among infertile women.^{[9],[11],[13],[15],[16]} A single study conducted among medical students reported a 37% prevalence.^[14] No population-based study for PCOS prevalence was available in the existing literature.

Table 1: Prevalence of polycystic ovary syndrome in Bangladesh

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Presentations of Polycystic Ovary Syndrome

Most of the studies conducted among Bangladeshi subjects with PCOS described the clinical presentations of the syndrome [Table 2].^{[13],[14],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27]} Menstrual irregularities, hirsutism, acne, subfertility, and polycystic ovarian morphology (PCOM) were the most frequently described presentations of PCOS though reported frequencies varied highly among the studies. The frequencies of menstrual irregularity ranged from 60% to 100%; oligomenorrhea was the most common type of menstrual abnormality reported by these studies.^{[13],[14],[16],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27]} The frequency of hirsutism was 44%–97%; the cutoff values of modified Ferriman–Gallwey for defining hirsutism were not the same for the studies.^{[13],[14],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27]} Similarly, the reported frequencies of acne were as low as 7.4% to as high as 55.6%.^{[14],[16],[21],[22]} The study reported 14%–72% frequencies of subfertility.^{[13],[19],[21],[22],[24],[26],[27]} The reported frequencies of PCOM also varied greatly, ranging from 40.7%–95%.^{[13],[14],[16],[17],[19],[20],[21],[22],[24],[25],[26],[27]}

Table 2: Presentations of patients with polycystic ovary syndrome

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Phenotypic Characteristics of Polycystic Ovary Syndrome

Four studies categorized subjects with PCOS according to phenotypes [Table 3].^{[14],[21],[22],[28]} Two studies identified phenotype A as the most prevalent phenotype of PCOS;^[22],[28] phenotype B was most prevalent in the other two studies.^[14],[21]

Table 3: Phenotypic characteristics of patients with polycystic ovary syndrome

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Metabolic Characteristics of Polycystic Ovary Syndrome

The studies describing the metabolic characteristics of Bangladeshi women with PCOS are given in [Table 4].

Table 4: Metabolic characteristics of patients with polycystic ovary syndrome

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Obesity and central obesity

Twelve studies reported the prevalence of overweight/obesity, ranging from 38% to 87.3%.^{[13],[14],[16],[19],[21],[22],[23],[24],[25],[26],[27],[30]} The body mass index (BMI) cutoff to define obesity was not similar in the studies; some studies used BMI ≥23 kg/m² while others used BMI ≥25 kg/m² for categorizing the study subjects as overweight/obese. The prevalence of central obesity ranged from 35% to 84.6%, as reported by seven studies; again, some used waist circumference ≥80 cm while others used ≥88 cm to define central obesity.^{[16],[17],[22],[23],[25],[26],[27]} The reported prevalence of acanthosis nigricans by eight studies was 15%–82.2%.^{[14],[16],[17],[20],[21],[22],[25],[27]}

Hypertension

Nine studies reported the prevalence of elevated blood pressure (BP) [pre-hypertension or hypertension (HTN)] ranging from 3% to 37.1%.^{[16],[17],[19],[21],[22],[24],[25],[26],[27]} Among these, the prevalence of HTN (BP ≥140/90 mmHg) was 3%–9.3%;^{[24],[25],[26],[27]} that of pre-HTN (Systolic BP 120-139 or diastolic BP 80-89 mmHg) was 19.3%–34.6%.^[22],[25] One study reported 19% of subjects with BP ≥130/85 mmHg.^[16] The cutoff defining HTN was not defined in three studies reporting the prevalence.^{[17],[19],[21]}

Insulin resistance, diabetes, and prediabetes

We found ten studies reporting the prevalence of abnormal glucose tolerance (AGT, including diabetes, impaired fasting glucose, and impaired glucose tolerance), which ranged from 21.8% to 56%.^{[16],[17],[19],[20],[21],[22],[25],[27],[28],[30]} The reported prevalence of diabetes was 4.9%–10%.^{[16],[20],[25],[27],[28],[30]} 16%–77% of the study subjects had insulin resistance (IR), as reported by seven studies.^{[19],[20],[23],[26],[27],[28],[29]} IR was not clearly defined in two of these studies;^[19],[29] one study diagnosed IR by the presence of one or more of the following: fasting insulin >20 μU/ml, fasting glucose/insulin ratio <4.5, homeostatic model of the assessment of insulin resistance (HOMA-IR)>3.8 in this study;^[28] HOMA-IR cutoff >2 defined IR in another study;^[23] while others used HOMA-IR ≥2.6.^{[20],[26],[27]}

Dyslipidemia and metabolic syndrome

Dyslipidemia prevalence was 45.7% to 93.7%, as reported by four studies.^{[17],[22],[23],[25]} Having one or more of total cholesterol (TC) ≥200 mg/dL, low-density lipoprotein (LDL) cholesterol ≥100 mg/dL, high-density lipoprotein (HDL) cholesterol <40 mg/dL, and triglyceride (TG) ≥150 mg/dL defined dyslipidemia in two studies (93% and 90.4% prevalence);^[22],[25] while the presence of one or more of the same cutoffs for TC, HDL, TG, and LDL ≥130 mg/dL was used by another (93.7% prevalence);^[23] the criteria were not defined in the other study reporting 45.7% prevalence).^[17] One study reported the frequencies of subjects with TC ≥200 mg/dL, HDL cholesterol <50 mg/dL, and TG >150 mg/dL as 16%, 12%, and 12%, respectively.^[16] The prevalence of metabolic syndrome was reported by nine studies, which ranged from 15% to 57%.^{[16],[17],[20],[21],[22],[23],[25],[27],[28]} The prevalence of metabolic syndrome using international diabetes federation criteria in three studies ranged from 42.9% to 57%;^{[22],[23],[27]} the range was 15% to 50.5% in the four studies using the National Cholesterol Education Program Adult Treatment Panel III criteria.^{[16],[20],[25],[28]} Other studies did not mention the diagnostic criteria of metabolic syndrome.^[17],[21]

One study assessed the use of neck circumference (NC) as a tool to define obesity, central obesity, and metabolic syndrome in subjects with PCOS.^[31] NC positively correlated with some other metabolic parameters and testosterone levels. NC cutoff 32.75 cm showed 87.3% sensitivity and 74.4% specificity in detecting abdominal obesity and 88% sensitivity and 68.0% specificity for diagnosing overweight/obesity, while NC 34.25 cm showed 63.0% sensitivity and 64.0% specificity for the diagnosis of metabolic syndrome.^[31] In another study, Banu et al. identified that lipid accumulation product had more associations with cardiometabolic risks (age, systolic and diastolic blood pressure, and total and low-density lipoprotein cholesterol) than visceral adiposity index and was a moderate discriminator of IR in lean PCOS.^[32] Albuminuria (albumin-creatine ratio ≥30 mg/g) as a cardiovascular risk marker in PCOS was investigated in one study; the frequency was 21.1%. Albuminuric subjects had higher plasma glucose values at 2 h of oral glucose tolerance test and a higher frequency of metabolic syndrome than nonalbuminuric ones.^[33]

Vitamin D in Polycystic Ovary Syndrome

Two studies reported Vitamin D status in PCOS.^[34],[35] One study said none of the women with PCOS and healthy volunteers were sufficient (≥30 ng/mL) of Vitamin D; Vitamin D insufficiency, deficiency, and severe deficiency were 25%, 68.33%, 6.67% of women in the PCOS group; in the control group, the frequency was 12%, 50%, and 38%, respectively.^[34] In the other study, the frequency of Vitamin D deficiency was 65.5%; the frequency was higher in subjects with metabolic syndrome who also had lower Vitamin D levels than those without metabolic syndrome. The study also found positive correlations between vitamin D levels with plasma glucose after 2 h of oral glucose tolerance test, TG, total, and LDL-cholesterol.^[35]

Hormonal Parameters in Polycystic Ovary Syndrome

Fourteen studies describing the hormonal characteristics of PCOS are summarized in [Table 5].^{[13],[14],[16],[17],[18],[19],[21],[24],[25],[26],[27],[36],[37],[38]}

Table 5: Hormonal characteristics of patients with polycystic ovary syndrome

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Biochemical hyperandrogenism in polycystic ovary syndrome

The prevalence of biochemical hyperandrogenism in PCOS reported by eight studies was 19.6%–52.5%.^{[13],[14],[16],[24],[25],[26],[27],[38]} All these studies measured serum total testosterone (TT), although the assay method and cutoff values of TT to detect biochemical hyperandrogenism were not unique.

Hyperprolactinemia in polycystic ovary syndrome

Six studies reported prolactin status in PCOS, and the prevalence was 6%–60%.^{[16],[17],[18],[21],[36],[38]} The studies were conducted among divergent groups of subjects with PCOS; subfertile women with PCOS had the highest frequency of hyperprolactinemia.^[36] All these studies used serum prolactin >25 ng/mL to define hyperprolactinemia. None of these studies revealed follow-up data for such high prolactin levels.

Thyroid dysfunction in polycystic ovary syndrome

We found eight studies reporting thyroid hormone status in PCOS; the prevalence ranged from 11.4% to 74%.^{[14],[16],[17],[18],[21],[36],[37],[38]} Most studies defined thyroid dysfunction as elevated levels of thyroid-stimulating hormone (TSH), including those with mildly elevated TSH, though the cutoff values were not similar. The study reporting the highest prevalence of 74% was a single-centered study with only 50 samples of subfertile women.^[36] Only one multicenter study described thyroid dysfunction categories; the prevalence of thyroid dysfunction was 17% (subclinical hypothyroidism 11%, overt hypothyroidism 5.2%, subclinical hyperthyroidism 0.4%, and overt hyperthyroidism 0.4%). This study also reported the prevalence of anti-thyroid peroxidase (anti-TPO) in subjects with PCOS, which was 20.6%.^[38] One study searching the impact of subclinical hypothyroidism on clinical and metabolic parameters in PCOS found that subclinical hypothyroid women with PCOS had similar frequencies of dysglycemia, dyslipidemia, and metabolic syndrome.^[39] Another study conducted to explore the relationship of IR with TSH found no association between them.^[37]

Luteinizing hormone to follicle-stimulating hormone ratio in polycystic ovary syndrome

Seven studies reported luteinizing hormone/follicle-stimulating hormone (LH/FSH) ratio in PCOS; the prevalence of altered LH/FSH ratio with cutoff >2 used in five of these studies ranged from 22.3% to 60%.^{[13],[16],[19],[21],[26]} Other two studies defined altered LH/FSH as >1 and found a higher prevalence of 70.7% and 75.5%.^[24],[27] One study found a predictive association of LH/FSH ratio with hyperandrogenemia in women with PCOS.^[24]

Anti-MÜLlerian Hormone in Polycystic Ovary Syndrome

Two studies evaluated serum anti-müLlerian hormone (AMH) levels as a diagnostic tool for PCOS; AMH levels were higher in the PCOS group than in the control group.^[40],[41] Sadiqa-Tuqan et al. (2016) identified 67% sensitivity and 78.33% specificity of AMH with the cutoff value at 3.5 ng/mL.^[40] The optimal sensitivity and specificity were achieved at a cutoff level of 4.85 ng/mL, as reported by Afreen et al. (2020).^[41]

Other Metabolic and Endocrine Parameters in Polycystic Ovary Syndrome

One study found higher serum prostate-specific antigen levels in PCOS than in healthy controls and a positive correlation of prostate-specific antigen levels with polycystic ovarian morphology in the PCOS group.^[42] In another study, Mohana et al. (2022) found higher leptin levels and leptin/adiponectin ratio in PCOS than in controls. They observed negative correlations between leptin levels and waist circumference, waist/hip ratio, and waist/height ratio. PCOS group had significantly higher cardiovascular risks than the healthy control when they were categorized according to the adiponectin/leptin ratio in the study.^[43]

Characteristics of Adolescents with Polycystic Ovary Syndrome

Only one study conducted by Kamrul-Hasan et al. (2021), evaluated adolescents diagnosed with PCOS.^[44] In the study, 27.4% of participants had a first-degree relative with PCOS, and 12% had a first-degree relative with type 2 diabetes. Oligomenorrhea was the most common (88%) menstrual problem; 77.7% had acanthosis nigricans, 69.1% were overweight or obese, 6.3% were underweight, 65.7% had central obesity, 23.4% had elevated BP, 24% had abnormal glucose tolerance (prediabetes 21.1%, diabetes 2.9%), 90.9% had dyslipidemia, and 42.3% had metabolic syndrome.^[44]

Characteristics of Lean Polycystic Ovary Syndrome

One study evaluated women with PCOS (BMI <23 kg/m²); the frequency was 23.3% of 523 women with PCOS.^[25] Although metabolic abnormalities are more frequently observed when obesity is associated with PCOS, lean women with PCOS also have adverse metabolic consequences (acanthosis nigricans in 45.9%, prediabetes in 13.1%, diabetes in 1.6%, prehypertension in 9.8%, hypertension in 0.8%, and metabolic syndrome in 14.8%).^[25]

Oxidative Stress in Polycystic Ovary Syndrome

One study reported that the levels of antioxidant Vitamins A and C were lower in PCOS cases compared to the healthy pregnancy group.^[45] This study and the other two studies found higher plasma malondialdehyde levels in PCOS than in the control group, indicating higher oxidative stress in PCOS.^{[45],[46],[47]} Lower plasma catalase (a marker for antioxidant) levels in PCOS than in controls described by the latter two studies demonstrate poor antioxidant status in PCOS.^[46],[47] Furthermore, measures of sympathetic reactivity and reduced parasympathetic activity were related to oxidative stress in PCOS.^[46],[47]

Psychiatric Comorbidities in Polycystic Ovary Syndrome

Two studies searched for psychiatric comorbidities in PCOS.^[48],[49] PCOS was associated with a 5.12-fold higher risk of major depression, according to Kamrul-Hasan et al. (2020).^[48] The frequency of depression assessed by administering the PRIME-MD Patient Health Questionnaire was 80% in PCOS (mild 29%, moderate 29%, moderately severe 14.5%, and severe 7.5%), and prediabetes/diabetes was identified as the risk factor of major depression in this study.^[48] Another internet-based survey revealed that 71%, 88%, and 60% of women with PCOS suffered from loneliness, generalized anxiety disorder, and depressive illness, respectively.^[49] According to the study, financial condition, physical exercise, mealtime, food habit, daily water consumption, birth control method, and long-term oral contraceptive pills contribute to the development of mental health disorders among females with PCOS in Bangladesh.^[49]

Conclusion

To date, no large-scale community-based data are available describing the prevalence and characteristics of women with PCOS in Bangladesh. Nevertheless, available data warn of the high prevalence of PCOS in the country. The data also remind of emphasizing the routine screening of comorbidities of PCOS, especially the cardiovascular and psychiatric ones. Large-scale, multicenter, community-based studies are of utmost importance to clearly describe the disease in the country.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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