A nationwide cross-sectional study to analyse the impact of the COVID-19 pandemic on lifestyle and manifestations of polycystic ovarian syndrome among clinically diagnosed polycystic ovarian syndrome cases aged 15-49 years

INTRODUCTION

Polycystic ovarian syndrome (PCOS), more commonly known as PCOS, is a gynecological health problem caused by an imbalance of reproductive hormones. It is characterized by androgen excess, multiple ovarian cysts and anovulation/oligoovulation.¹ Presenting itself as a multifactorial disease, it can be affected by genetic/environmental factors, uncontrolled ovarian steroidogenesis, aberrant insulin signalling and excessive oxidative stress.² Family history is found to have the strongest association with the disorder, with a high significance.³ Features commonly observed include menstrual dysfunction (menses could be infrequent, too frequent, or even absent), hirsutism, acne, and alopecia.⁴

In 2003, Rotterdam's three diagnosis criteria were established, out of which if the female presented with any two of them, she is diagnosed to have PCOS.⁵ The diagnostic criteria comprise of oligo and/or anovulation, clinical and/or biochemical hyperandrogenism and polycystic ovaries on ultrasonography.⁶

The prevalence of PCOS in India ranges from 3.7 to 22.5 per cent (2017).⁷ A study conducted in 2020 with 100 PCOS patients showed that 34% were lesser than 19 years of age, 57% were between 20-30 years and 9% greater than 30 years of age.⁸

Based on socioeconomic status, a study conducted in September 2014 to April 2015, showed that a higher percentage of girls with PCOS belong to the upper socioeconomic class (45.37%) as compared to those without PCOS (35.43%).⁶ While based on area of stay, the prevalence of PCOS was higher in the urban group (20%) as compared to that of the rural group (4%), in a study conducted from March 2019 to September 2019.⁸

The management of PCOS is complex, and mainly includes a healthy diet, regular physical activity, and medications, which address the associated manifestations as well as comorbidities. Both non-pharmacological and pharmacological management strategies are important in the overall management of PCOS.⁷

The COVID-19 pandemic has caused most countries to impose lockdowns, resulting in a massive impact on physical activity, quality of life and mental health.⁹ The sudden disruption from normal life combined with uncertainty, has resulted in a negative impact on the eating habits, stress and psychosocial well-being of the target population. High stress levels and emotional instability has been proven to be linked to dysmenorrhea, which is further aggravated in our target population - women with PCOS.^10-12

Based on a study conducted during the COVID-19 pandemic, 44.2% of participants reported a negative impact on sleep.¹³ They also reported a negative impact on their quality of life based on PCOS QoL in the form of a poorer mood. These participants also showed higher levels of depression and stress levels.

Therefore, keeping in mind the recent pandemic, this research aims to study: the effect of the COVID-19 pandemic on the lifestyle of women with PCOS; to study the effect of the COVID-19 pandemic on the manifestations in women with PCOS; and to study the association between changes in lifestyle - diet, sleep, exercise and stress, with the change in the manifestations of PCOS.

METHODS

A nationwide cross-sectional study was carried out in two stages, by first circulating an online consent questionnaire using a Google form, via social media, i.e., Instagram - @falgunivasavada, @satshyaa, @slayingpcos, @saki_women, @wethecysters, @pcosandcysters, @pcodecoded, @pcos_theindianway, @cysterlyhealth, @pcos.holistic.coach, @teamtaarini; WhatsApp - CYSTER SUPPORT GROUP; and Telegram - PCOS CLUB INDIA ~ Tribe, PCOS fighters’ group to filter out our target population, i.e., women diagnosed with PCOS, via Rotterdam's criteria.⁵ For that, the second stage focused on individually contacting the 263 females aged 15-49 years, who had replied in affirmative to the consent form, inquiring about the effect of the pandemic on various factors, over the period of one year, from June 2020 to June 2021, via a pre-designed, semi-structured questionnaire. The participating females were filtered based on the following criteria.

Inclusion criteria

According to the Rotterdam’s criteria, women who have at least 2 of the following: ultrasound diagnosis of PCOS, history of menstrual irregularities - amenorrhoea/ oligomenorrhoea, presence of hirsutism/ acne; women of reproductive age group -15-49 years; and women who consented to take part in the study were included.

Exclusion criteria

Women less than 15 years or more than 49 years, women with congenital adrenal hyperplasia, androgen secreting tumours, and hyperprolactinemia, pregnant women, breastfeeding women - lactational amenorrhoea, and women who did not give consent for the study were excluded.

The data collected included a wide range of questions inquiring about the socio-demographic profile of the respondents, health status, including premenstrual symptoms, associated features of PCOS such as acne and hirsutism, and menstrual cycle characteristics, i.e., menstrual cycle irregularity, missed menstrual cycles (as occasionally/often/never) and menstrual flow (as increased/decreased/no change) and BMI, as per the South Asian anthropometric classification.¹⁴

They were also asked about their lifestyle patterns during the COVID-19 lockdown based on factors such as exercise, dietary habits, sleep and stress, both prior to the pandemic and during the pandemic, in order to obtain a comparison between their pre-pandemic and during the pandemic manifestations of PCOS.

To assess anxiety, the GAD-7 assessment system was used, which graded them based on 7 parameters, using a 4-point system ranging from 0 (not at all) to 3 (more than half the days) to classify them as having minimal, mild, moderate, or severe anxiety, the cut-offs for the same being 5, 10 and 15, respectively.¹⁵

The correlation between the manifestations of PCOS (regularity of menses and changes in pattern of body hair) and lifestyle measures (weight, diet, sleep pattern, physical activity, GAD score¹⁵ and stress levels) was done using the Chi-square test. P value <0.05 was considered significant.

Aside from the questions to assess the changes in various aspects of their lifestyle prior to and during the pandemic, open ended questions were also asked so as to allow the respondents to allow themselves to be heard, at the end of the questionnaire.

RESULTS

Of the 263 participants, PCOS cases were significantly more in the age group of 20 to 29 years (206 (78.3%)). Of these, 220 (83.7%) were single women, more than half of them being students - 145 (55.1%) participants. It was a notable finding that most participants were unemployed, but working full time from home during the pandemic (e.g., student and housewife) with a mean age of 24.5 years, amounting to 51.3% (135) of the total, and a change towards working more from home was reported by 107 (40.7%) women (Table 1).

As many as 144 (54.8%) women belonged to the obese category (BMI ≥30 kg/m²) while 41 (15.8%) and 17 (6.5%) women were of overweight (BMI 25-30 kg/m²) (Table 1). Some women remarked that they were in distress concerning their weight gain and PCOS symptoms particularly being impacted during the pandemic.

A comparative analysis between pre and whilst the pandemic experience of participants showed that more than half, i.e., 62.4% who reported irregular cycles during the pandemic compared to 57.8% participants who had irregularities previously as well. 103 (39.2%) women often, and 88 (33.5%) women occasionally missed their cycles during the pandemic. Menstrual flow was reported as ‘increased flow’ by 54 (20.5%) participants during the pandemic (Table 2).

Women in our study, were reported to have noticed increased irregularities (62.4%), and worsened dysmenorrhea (44.3%) during the pandemic.

As many as 93 (35.4%) women in our study reported an increase in facial and body hair during the pandemic, in contrast to 167 (63.5%) women who already presented with these symptoms before the pandemic (Table 2). Crucial responses of most participants include them observing thicker and coarser facial hair, emphasizing its notable increase during the pandemic period.

A wide variety of premenstrual symptoms was manifested among women who did not have them prior to the pandemic. This includes 11.4% who started experiencing mood swings/depressed mood and 2.7% who newly complained of acne. Change in breast tenderness, more bloating with cramping and appetite changes were complaints in 3.8%, 3.4% and 1.9% respectively. General worsening of the above symptoms was reported by 8.4% while these symptoms remained unchanged and have persisted even before the pandemic in 155 (58.9%) women (Table 2). Our participants described hyper-irritability, anxiety, fatigue, PMS flare of acne and mood swings, insatiable hunger, poor stress management; as premenstrual symptoms observed by them during the pandemic.

Weight gain was seen to be a common feature in 66.9% of the respondents, with an average gain of 6.62 kgs (Table 3).

A mere 12 out of our pool of 263 respondents claimed to have been highly physically active during the lockdown. Of the remaining 251, 125 were moderately active and 126 were sedentary (Table 3).

Overall, more than half (53.2%) of them said that their diet had gotten better than what it was, before the pandemic, whereas a little more than a quarter (28.5%). The consumption of junk food patterns was analyzed prior to, and over the course of the pandemic, and overall, 38.0% of the respondents said that they noticed a decrease in their junk food consumption during the pandemic (Table 3).

The change in stress levels was studied and compared, prior to the pandemic and during the pandemic, and it was observed that majority of the participants (72.6%) noticed an increase in their stress levels, with the prime contributing factor being work stress, or change in the employment status (43.7%) (Table 4).

When asked what they did to keep stress at bay, answers ranging from binge eating to gardening to meditation were received. Meditation (29), and consumption of media in the form of music (29) and visual content (48), were indulged in, the most. Some even took it upon themselves to channel their energy towards exercising (30). As many as 35 respondents expressed their helplessness as they couldn’t do anything to ward off stress (Table 4). A respondent said that she felt lethargic all the time, and that her inner self wouldn’t allow her to do anything. When the history of psychological disorders was considered, two-fifths had depression, one fifth had a history of eating disorders and three-fifths of the participants reported having anxiety. To understand this better, the GAD-7 assessment test was used to classify the participants.¹⁵ More than half of them (51.7%) were recorded to have severe anxiety, almost a quarter (25.9%) had moderate anxiety, and the rest were minimally to mildly anxious (Table 4).

Table 5 compares regularity of menses with different lifestyle measures. It was observed that when regularity of menses was compared with weight, physical activity, diet and GAD score, the p value was less than 0.05 and thus, there is significant association between regularity of menses and these lifestyle factors.¹⁵ On the contrary, the p value for stress levels and sleep pattern was greater than 0.05 and thus no significant association.

Table 6 compares changes in pattern of body hair with different lifestyle measures. Here, stress levels and sleep patterns show a p value less than 0.05 showing significant association. On the other hand, weight, physical activity, diet and GAD score were not found significant.

DISCUSSION

This study analyzed how the limitations resulting from the COVID-19 pandemic have altered the clinical manifestations of women diagnosed with PCOS, during the first and second waves in India, between June 2020 to June 2021. The participants were questioned in detail about change in their symptoms during the pandemic and about the lifestyle changes they had to go through as a result of the pandemic. The symptoms and lifestyle changes were then correlated to establish an understanding regarding how the lifestyle changes could affect PCOS manifestations.

More than 90% of participants were found to be living under sedentary conditions during the pandemic. Similarly, Hillyard and Sinclair found a 79% increase in the sedentary time of women during the pandemic.¹⁶ Women who were constrained to work from home may have been sedentary for most of the pandemic duration.¹⁷

As the proportion of obese subjects are considerably high in our study population, focusing on their responses revealed an increased potential prevalence of classic phenotypic features of PCOS during the pandemic. Observations similar to ours were made in other studies like Kim and Lim showed a higher prevalence of clinical manifestations in obese females.¹⁷

As the clinical manifestations of PCOS like change in pattern of body hair (hirsutism) and regularity of menses can be gauged without the employment of clinical and laboratory investigations, we’ll further implore the association of factors such as weight, physical activity, diet, stress levels, sleep patterns and anxiety, with the above-mentioned clinical features.

In our study, upon the observation of change in the pattern of body hair (or hirsutism) in relation to the participant's weight, physical activity and diet, no significant correlation could be found, as opposed to the relation observed by an Iran based study conducted in people with PCOS, where a positive correlation was seen between hirsutism and one’s BMI.¹⁸

Our study could not establish a correlation between physical activity and hirsutism, and this could be described based on previous studies that have proved that exercise, unless of high intensity (HIIT or AHIIT) does not have a significant impact on hirsutism.^19,20

This can be explained by the mechanism of HIIT - where there is an increase in the intake of oxygen, which in turn improves one’s cardiovascular functioning, leading to increased oxidation of fat, which causes weight loss and an improvement in BMI.²⁰

It could be that in our population, the frequency and intensity of physical activity might not have been sufficient enough to qualify as HIIT as only a mere 5% were reported to have been highly active, engaging in walking or yoga, both of which aren't under HIIT, and majority of our population was moderately active or sedentary, citing issues such as lack of guidance and awareness.

Our study revealed a p value of 0.055 when the change in pattern of body hair was compared with anxiety, according to the GAD-7. Yet, a cross sectional study named anxiety, depression, and QoL (quality of life) in women with PCOS, was able to conclude that women with hirsutism had lower scores on the psychological domain measuring QoL. This was backed by an explanation that women with hirsutism spent more energy covering and hiding it and experienced low confidence because of the same which aggravated issues like anxiety and depression.^21,22

The negative psychological effects in terms of stress and anxiety directly translates to disturbed sleep patterns, and this corroborates the findings by a study conducted in the UK, during the COVID-19 lockdown.¹³

The decrease in libido observed in our respondents, might have resulted due to the physical alterations of PCOS, like hirsutism and acne, which can often make one more conscious about their appearance, as well as the associated hormonal imbalance, leading to lower sexual satisfaction.²³

Moving on to the regularity of menses, or lack thereof, observed in our study population, pitted against the same factors as hirsutism were analyzed, and the significance of the correlation was noted.

Around 70% of our respondents were seen to belong to the obese and overweight category, and weight gain in our study, was seen to be strongly related to the irregularity of menses in our study population, the p value being less than 0.0001. These findings are consistent with those of Khademi et al, who had a higher frequency of obesity in the subgroup of their study which included people with PCOS.²⁴ The pathogenesis behind obesity affecting manifestations of PCOS has been extensively explained by Barber TM, Franks S concluding that hyperinsulinemia in PCOS affects the reproductive hormonal levels as well as the ovarian follicular growth.²⁵

In this study, statistical data shows an increase in new findings of menstrual irregularities among the women to more than half since the pandemic onset. Our results are in correspondence with that of Nguyen and Pang study which proved a statistical rise in menstrual abnormalities along with potential covariates which may be responsible.²⁶ Weight gain as a covariate has shown a high positive correlation with irregular menses (p<0.0001) that manifests as anovulation with painful and erratic bleedings. Eyuboglu and Aksun study stated that the COVID-19 related social isolation was associated with an increase in BMI among the PCOS group.²⁷

Physical activity was found to have a very strong correlation with the irregularity of menses with a p value of 0.001. This corroborated the findings in a study conducted by Tayseer and Waleed, where they found that weight loss led to a more regular menstrual cycle.²⁸

Diet, in our study, also has a correlation with the regularity of menses, with a p value of 0.0468. According to studies, worsening of one’s diet leads to an increasing irregularity of menses in our study population, which can be explained by leptin being produced by adipose tissue cells, which leads to a gonadotropin surge, leading to further menstrual irregularities.^29,30

A meta-analysis accessing sleep problems during the pandemic revealed a 40% increase among the general population during the pandemic.³¹ Our study shows that issues with sleep have risen by about 9% among women with PCOS during the pandemic. Studies also show that women with sleep disturbances and stress experienced missed periods and worsening of PMS.¹³

A correlation was made between menstrual irregularities and GAD score of our participants (p=0.0093).¹⁵ Most women quote to have experienced severe episodes of anxiety occasionally. The study results of Phelan and Behan, conducted as an anonymous digital survey proved psychological distress of the pandemic to cause significant menstrual disturbances.¹²

Our study had its limitations. It included only a small number of women from all over India. Therefore, this group of women may not have been a proper representation of the entire PCOS community of India. This makes it difficult to implement these findings on an entire population but this gives us a basic idea regarding the factors influencing women with PCOS and therefore it can prove to be a good foundation to understand PCOS.

Secondly, we relied on self-reporting. Self-reporting is often liable to errors and there can be over- or under presentations of their symptoms. Yet we believed that an online survey was a better option keeping in mind the pandemic, hesitancy of women with PCOS to publicly accept their disorder and pan-India nature of the study. Also, this study focused on the period between June 2020-2021. So, there could’ve been recall bias as well. Many women may have noticed changes only in specific few months.

CONCLUSION

PCOS, a multifactorial disease that results in both gynecological and endocrinological abnormalities, is diagnosed using Rotterdam's criteria. While there is no standard treatment established for PCOS, various lifestyle factors can cause fluctuations in manifestations of PCOS. We noticed a minor change in the manifestations of PCOS when comparing them to pre pandemic states. While on the other hand we could assess that most participants experienced a negative impact on their lifestyle mainly including stress, generalized anxiety and depression, weight and sleep. Therefore, on comparing the lifestyle and manifestations of PCOS, it was found that there is an association between regularity of menses and weight, physical activity, diet and generalized anxiety disorder. We were able to relate the change in the pattern of body hair, to sleep, and stress.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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