Review of literature is an essential step in the development of a research project. The primary purpose is to gain abroad background or understanding of the information that is related to the research problem.
Review of literature of the present study was arranged in the following heading:
Review related to polycystic ovarian syndrome.
Review related to prevalence
Review related to Quality of life
Review related to risk factors.
Review related to treatment.
. Review related to poly cystic ovarian syndrome.
Polycystic ovary syndrome (PCOS), also known as Stein Leventhal Syndrome, was first described in 1935. PCOS, which may also be referred to as polycystic ovary disease (PCOD) is the most common hormonal disorder found in premenopausal women. PCOS affects 7% of women from all races and nationalities.
Typically, PCOS symptoms first appear in adolescence, normally around the state of menstruation. Occasionally, some women do not develop PCOS symptoms until their early to mid-20s. One of the most common symptoms of PCOS is irregular periods. Polycystic ovary syndrome (PCOS) becomes symptomatic during adolescence and affects at least 5% of reproductive-age women. PCOS is a heterogeneous syndrome of unexplained chronic hyperandrogenism and oligo-anovulation, with a polycystic ovary being an alternative diagnostic criterion. About half of cases lack some of the classic Stein-Leventhal syndrome features of menstrual irregularity, hirsutism, obesity, and polycystic ovaries. Whether the syndrome can be diagnosed in the absence of hyperandrogenism is controversial, and the documentation of hyperandrogenemia can be problematic. The broad spectrum of the disorder seems to encompass atypical cases of hyperandrogenemia with central obesity and features of insulin resistance instead of hirsutism or anovulation.
Functional ovarian hyperandrogenism (FOH) is usually the source of the androgen excess. It is characterized by 17-hydroxyprogesterone (17PROG) hyperresponsiveness to the gonadotropin stimulation of GnRH agonist or human chorionic gonadotropin testing and subnormal suppressibility of plasma testosterone upon adrenal suppression by glucocorticoid. It is often accompanied by functional adrenal hyperandrogenism, characterized by 17-hydroxypregnenolone or dehydroepiandrosterone (DHEA) hyperresponsiveness to ACTH; in atypical PCOS, the sole source of androgen excess may be functional adrenal hyperandrogenism. The underlying defect seems to be a constitutive dysreglulaton of steroidogenic cells (9). Intrinsic granulosa cell dysfunction is also present. LH excess appears to contribute to 50-75% of cases. Evidence is accumulating that it arises from androgen interfering with the progesterone negative-feedback effect on LH secretion. However, the possibility of primary central mechanisms for LH excess remains, particularly in adolescent PCOS .
Increasing evidence suggests that PCOS arises as a complex trait with contributions from both heritable and nonheritable factors. Polygenic influences appear to account for about 70% of the variance in pathogenesis. Nearly half of sisters of women with PCOS have an elevated plasma testosterone level, although only half of them are symptomatic. Polycystic ovaries appear to be transmitted as a dominant trait, usually asymptomatic but often accompanied by a subclinical PCOS type of ovarian dysfunction. Central obesity and insulin resistance seem to play important roles in PCOS, perhaps by accentuating steroidogenic dysregulation but perhaps more fundamentally because PCOS is closely related to these features in parents. Gestational factors have also been incriminated; the syndrome has been associated with high birth weight in heavy mothers and can arise from fetal programming by androgen excess. In view of these indications for congenital origins of the syndrome, it is not surprising that there is increasing recognition of risk factors for PCOS in childhood
Minerva Pediatr (2010) Polycystic Ovary syndrome (PCOS) is a complex disorder, involving primarily ovarian hyperandrogenism in females and linked with insulin resistance in the majority of cases. Clinical features are widely variable and include a combination of menstrual irregularities, acne, hirsutism, and alopecia. Although it typically presents around puberty, several risk factors during childhood may help raise a high index of suspicion for the development of PCOS in adolescents. The pathophysiology of PCOS still remains unknown and likely includes a combination of genetic factors, insulin resistance and environmental factors. A thorough diagnostic work up is required in suspected cases and several management modalities have been suggested. Since various long term complications and comorbidities are associated with PCOS early diagnosis and therapeutic intervention is warranted in these cases.
Review Related To Prevalence
Pembe AB, Abeid MS (2009). The aim of this study was to determine prevalence of polycystic ovaries (PCO) and associated clinical and biochemical features among women with infertility attending gynaecological outpatients department (GOPD) at Muhimbili National Hospital (MNH) in Dar es Salaam, Tanzania. All women with infertility attending the GOPD from 11th September 2006 to 15th February 2007 were recruited to the study. Information on socio-demographic, obstetric and menstrual characteristics was collected. Anthropometric measurement, clinical examination of acne and hirsutism, vaginal ultrasonography for PCO and biochemical analysis of luteinizing hormone (LH), follicle stimulating hormone (FSH) and testosterone were performed all 102 women who attended the GOPD during the study period due to infertilityw ere recruited. Two women were excluded after diagnosis of pregnancy made by hormonal assay and ultrasonography thus remaining with 100 women for analysis. Oligomenorrhoea and acne were significantly higher in a group of women with PCO than among women with normal ovaries. The mean hirsutism score though was not significant, was higher in women with PCO than in women with normal ovaries (5.1 +/-2.7 vs 4+/-2.4, P<0.057). Using the Rotterdam criteria 32 (32%) women were diagnosed to have polycystic ovary syndrome (PCOS). Among these women 25 (78.1%) had PCO, 24 (75%) had signs and oligoanovulation, and 18 (56.3%) had hirsutism. Among 68 women with no PCOS, 7 (10.3%) had polycystic ovaries, 15 (22.1%) had signs and oligoanovulation and 6 *8.8%) had hirsutism. In conclusion, polycystic ovaries are common among women with infertility, however are not necessarily associated with polycystic ovary syndrome.
Koivunen R. (1999) conducted study about prevalence of polycystic ovaries in healthy women. The prevalence of polycystic ovaries varies with age. The findings are more common in women aged 35 years or younger than in those aged 36 years or older. It remains unclear of women with polycystic ovaries will later develop fall-blown polycystic ovary syndrome; however, the hormonal parameters and clinical findings among women with polycystic ovaries mimized those will polycystic ovarian syndrome.
Enhrman DA, Cavagham MK, Barnes RB, (1999) prevalence of impaired glucose tolerance and diabetes in women with polycystic ovary syndrome obese women with polycystic ovary syndrome have the highest risk of glucose intolerance. Among women with polycystic ovary syndrome, 35% will have impaired glucose tolerance and 10% will be diabetic before age 40. Hyperandrogenemia may have a role in the development of glucose intolerance or be a marker of insulin resistance. Conversion from impaired glucose tolerance to NIDDM appears to be accelerated in women with polycystic ovary syndrome.
Review related to quality of life
Moran L, el.a.l (2010) conducted a observational, cross – sectional study in young woman. He assess the psychological features in young women with and without PCOS. Women with PCOS demonstrated worsened quality of life (p=0.033 ) and greater anxiety (p= 0.01)and depression (p=0.023) than women without PCOS related to BMI status. Women with PCOS were more likely to perceive themselves as at risk of obesity (p=0.012) and infertility (p=0.0001), and perceived greater importance in reducing future risk of prediabetes (p=0.027), gestationl diabetes (p=0.039),type2 diabetes (p= 0.01) , heart disease (p=0.005),obesity(p=0.0007),and infertility(p=0.023) than women without PCOS. Women with PCOS were more likely to have fears about future health related to weight gain (p=0.045 ), loss of femininity (p =0.035) , loss of sexuality (p =0.003) and infertility (p=0.019) than women without PCOS. Worsened quality of life, anxiety and depression in young women with PCOS is related to BMI. Risk perception is appropriately high in PCOS, yet perceived risk of future metabolic complications are less common than those related to weight gain and infertility.
Judy Griffin Mc Cook, et al conducted on a cross – sectional, regarding quality of life in women with polycystic ovarian syndrome. The results of this study indicate that women with PCOS have the greatest concern in the area of weight, followed by menstrual problems and infertility. These concerns are directely reflected in their objective life experiences. Women with PCOS clearly need education and support regarding the effect of their quality of life.
Sigrid elsenbruch el.al They conducted a survey method the sample was collected from out patients clinics of the devision of endocrinology ,department of medicine at the university of essen, based on referrals from gynecologists in the surrounding area or patients attracted by the clinic’s home page. They concluded that the pronounced psychological and psychosocial problems affecting health related to quality of life of patients with PCOS. Although an effective medical treatment aimed at improving PCOS – related symptoms will also reduce psychological distress and improve sexual self – worth , consideration of both the medical and psychological situation with the availability of an additional help group are likely to further improve life satisfaction and coping of affected women.
Maria E el. al conducted a cross sectional study of female adolescents and to determine whether clinically observed or self -perceived severity of illness attect their HRQL (Health related quality life) they concluded that adolescents with PCOS experience lower HRQL compared with healthy adolescents. Polycystic ovarian syndrome and perceived severity of illness negatively affect HRQL in adolescents. This study suggests a need to develop interventions to reduce the distress that patients with PCOS may face to adolescents and young adult.
Susanne Hahn, el. al A Comparative study was conducted in out patient clinic of The Department Of Medicine, university of Duisburg – Essen, Germany. The result of the study was PCOS patients showed significant reductions in quality of life, increased psychological disturbances, and decreased sexual satisfaction when healthy controls. BMI and hirsutism scores, but not the presence of acne , were associated with physical aspect of quality – of – life and sexual satisfaction. No clear effect of androgens or insulin resistance on psychosocial variables was detected. Similarly, the type of menstrual cycle disturbances or infertility had no impact on psychological well – being.
Review related to risk factors
Robert L. Rosenfield et al 2007 in this study state that risk factors for PCOS can be recognized in childhood. This study concluded that premature pubarche patients appear to carry about a 15 -20 % risk of developing PCOS. It seems likely that the risk is relatively high in those with exaggerated adrenarche and relatively low in those with ordinary premature adrenarche or idiopathic premature pubarche. PCOS is a complex trait with a large hereditary component. There fore, the presence of PCOS, or central obesity, diabetes, or other insulin resistant features in a parent should heighten the concern about risk for PCOS if the child presents other risk factors.
Bulent O. Yildiz, et.al (2005) The study was conducted at a tertiary care center. Population prevalence of PCOS according to body mass index (BMI) and change in BMI of PCOS patients over time were measured. The results suggest that the risk of PCOS is only minimally increased with obesity, although the degree of obesity of PCOS patients has increased, similar to that observed in the general population. These data indicate that obesity in PCOS reflects environmental factors to a great extent.
Meher un Nisal (2009) A cross – sectional analytical study was conducted in Qassim University Clinic, in the year of 2007 -2009 . They concluded that obesity plays an important role in the genesis and maintenance of polycystic ovarian disease. PCOD is the leading cause of anovultory infertility in females and affects 1 in 10 women of reproductive age. PCOD is strongly associated with obesity.
Angela Kerchner, B.A., el .al (2009) coducted a prospective longitudinal study cocluded that there is a significant risk mood disorders in women with polycystic ovarian syndrome. The persistent high rate of depression and other mood disorders are presents in young women with PCOS.
Rosenfield RL. The University of Chicago Pritzker School of Medicine, Department of Pediatrics (2007) conducted a study on polycystic ovary syndrome (PCOS) appears to arise as a complex trait with contributions from both heritable and nonheritable factors. Polygenic influences appear to account for about 70% of the variance in pathogenesis. In view of this evidence for congenital contributions to the syndrome, childhood manifestations may be expected. The objective has been to review the evidence that risk factors for PCOS can be recognized in childhood. Congenital virilizing disorder are average or low birth weight for gestation age; premature adrenarche, particularly exaggerated adrenarche; atypical sexual precocity; or intractable obesity with acanthosis nigricans, metabolic syndrome, and pseudo-cushing syndrome or pseudo-acromegaly in early childhood have been identified as independent prepubertal risk factors for the development of PCOS. During adolescence, PCOS may masquerade as physiological adolescent anovulation. Asymptomatic adolescents with a polycystic ovary occasionally (8%) have subclinical PCOS but often (42%) have a subclinical PCOS type of ovarian dysfunction, the prognosis for which is unclear. Identifying children at risk for PCOS offers the prospect of eventually preventing some of the long-term complications associated with this syndrome once our understanding of the basis of the disorder improves.
Fertile steril (2009) conducted a prospective longitudinal study in university they state that there is a significant risk for mood disorders in women with polycystic ovarian syndrome. They found that a high conversion risk for depression over a 1 to 2 year period under scores the importance of routine screening and aggressive treatment of mental health disorders in this population.
Duleba AJ, Ahmed IM (2010) observational study to evaluate urinary albumin excretion (UAE) in normotensive and non diabetic women with polycystic ovary syndrome in relation to their clinical, endocrine, and metabolic motiles. They concluded urinary albumin exenetion in women with pcos correlates well with other cordiovcescular events is continuous, evaluation of UAE in the presence of information and may aid in selecting appropriate patients for move aggressive treatment of likely aggravation factors, such as hyperonsulinemia or borderline hypertension.
Want Y, et.al says that the family history of diabetes mellitus has the most effect on the clinical phenotype in women with PCOS. The family history of other diseases such as menstrual disorder, premature balding and hypertension play less significant roles. A family history of positive coronary heart disease does not affect the clinical phenotype of such patients. A survey of the polycystic ovary syndrome in the Greek island of Lesbos: hormonal and metabolic profile.
Review related to Treatment
Moran LJ, Pasquali R, (2009) state that the lifestyle management should be used as the primary therapy in overweight and obese women with PCOS for the treatment of metabolic complications.
Jeans YM, et.al (2009) they conducted a experimental study on dietary management of women with PCOS. They concluded that 73% of overweight women were not following a diet to promote weight loss.
Humphreys L, costarelli V (2008). They concluded that in spite of the fact that weight loss and weight maintenance are absolutely vital in the treatment the PCOS. In their study bees shown that the support given to PCOS patients to help reduce and control their weight is inadequate and needs to be improved.
Hector F Escobar et.al. (2008). They done a case control study including 40 PCOS patients matched with 40 non hyperandrogenic women for age and body mass index. They concluded that serum OPG (Osteoprotegerin) concentrations are reduced in PCOS patients independently of obesity.
Unlu C. Atabe koglu CS. (2006). They suggest that the metformin has gained popularity as first line management in clomiphone citrate resistant women with polycystic ovarian syndrome. It ovulation does not occur within several months offer treatment with metformin, affer the evaluation of all PCOS and cons related to each treatment. Laparoscopic ovarian drilling or gonadotropins may be considered as an effective option according to patients choice.
Glueck CJ, et. Al. (2009 Sep) conduct a study: in 20 adolescents age, or = 17(16+/- 1 yr) with polycystic ovary syndrome (PCOS), endocrinopathy and coronary heart disease (CHD) risk factors. Median weight fell from 85.5 to 78.4 kg(p=0.004), waist circumference from 91 to 84 cm (p= 0.017), triglyceride form 108 to 71 mg/dl (p=0.026), and testosterone from 45.5 to 31.5ng/dl (p=0.03). The percentage of cycles with normal menses rose from a pre-treatment median of 8% to 100 %, p<0.0001. In adolescents ( Genazzani AD, Ricchieri F, Lanzoni C conducted a study in metformin is quite an old drug, but it is optimal for the control of glycemia in type 2 diabetes. It was reported, 15 years ago, that insulin resistance was abnormally high in most polycystic ovary syndrome (PCOS) patients. Starting disorder over 2 years after menarche, a higher incidence of obesity, marked hyperandrogenism and insulin resistance and disorderly gonadotropine secretion in comparison with control subjects. Hyperandrogenism and insulin resistance are much more severe in obese adolescent PCOS. Beata Banasjewska MD Ph.D., Antoni J Duleba MD, Robert Z. Spacjynski, “Lipids in polycystic ovarian syndrome Role of hyperinsulinemia and effects of metformin”.Use of metformin in hyperinsulinemia women with PCOS is associated with a significant improvement of lipid profile; these findings support the notion that metformin use may be considered prophylactic therapy aimed at lowering cardiovascular risk factors. Jeans YM et al (2009) conducted a study related to dietary management of women with polycystic ovary syndrome. Advice provided by dietitians focused on a reduction in energy intake (78%) and dietary glycaemic index (77%) often in combination. Of the women with poly cystic ovarian syndrome who were following a diet specifically for their poly cystic ovarian syndrome (57%) regimes included a low glycaemic index (34%), weight loss diets (16%) or a combination (26%). Of interest, 73% of overweight women were not following a diet with only 15% of women having seen a dietitian. Eighty-four percent of women with poly cystic ovarian syndrome who had increased physical activity (48%) self-reported an improvement in their symptoms. They concluded that women with poly cystic ovarian syndrome recognize the importance of diet, but few received dietary advice from a registered dietitian. The dietary information women with poly cystic ovarian syndrome received was often from an unregulated source. A consensus statement of evidence-based dietary advice for women with poly cystic ovarian syndrome is needed and would be a useful resource for dietitians.
Genazzani AD, Ricchieri F, Lanzoni C conducted a study in metformin is quite an old drug, but it is optimal for the control of glycemia in type 2 diabetes. It was reported, 15 years ago, that insulin resistance was abnormally high in most polycystic ovary syndrome (PCOS) patients. Starting disorder over 2 years after menarche, a higher incidence of obesity, marked hyperandrogenism and insulin resistance and disorderly gonadotropine secretion in comparison with control subjects. Hyperandrogenism and insulin resistance are much more severe in obese adolescent PCOS.
Beata Banasjewska MD Ph.D., Antoni J Duleba MD, Robert Z. Spacjynski, “Lipids in polycystic ovarian syndrome Role of hyperinsulinemia and effects of metformin”.Use of metformin in hyperinsulinemia women with PCOS is associated with a significant improvement of lipid profile; these findings support the notion that metformin use may be considered prophylactic therapy aimed at lowering cardiovascular risk factors.
Jeans YM et al (2009) conducted a study related to dietary management of women with polycystic ovary syndrome. Advice provided by dietitians focused on a reduction in energy intake (78%) and dietary glycaemic index (77%) often in combination. Of the women with poly cystic ovarian syndrome who were following a diet specifically for their poly cystic ovarian syndrome (57%) regimes included a low glycaemic index (34%), weight loss diets (16%) or a combination (26%). Of interest, 73% of overweight women were not following a diet with only 15% of women having seen a dietitian. Eighty-four percent of women with poly cystic ovarian syndrome who had increased physical activity (48%) self-reported an improvement in their symptoms. They concluded that women with poly cystic ovarian syndrome recognize the importance of diet, but few received dietary advice from a registered dietitian. The dietary information women with poly cystic ovarian syndrome received was often from an unregulated source. A consensus statement of evidence-based dietary advice for women with poly cystic ovarian syndrome is needed and would be a useful resource for dietitians.
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