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Hariri Z, Yari Z, Hoseini S, Mehrnami A, Abhari K, Sohrab G. Effects of Synbiotic-Containing Bacillus coagulans (GBI-30) on the Cardiovascular Status of Patients With Polycystic Ovary Syndrome: A Triple-blinded, Randomized, Placebo-controlled Study. Clin Ther 2023; 45:e193-e199. [PMID: 37640616 DOI: 10.1016/j.clinthera.2023.07.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 07/19/2023] [Accepted: 07/29/2023] [Indexed: 08/31/2023]
Abstract
PURPOSE Despite the high risk of cardiovascular diseases in women with polycystic ovary syndrome, fewer studies have addressed the improvement of cardiometabolic status of these patients. This study was conducted with the aim of investigating the effects of synbiotic-containing, spore-forming Bacillus coagulans on cardiometabolic indicators, including lipid profile, C-reactive protein, and atherogenic indexes in patients with polycystic ovary syndrome. METHODS In the present 12-week, triple-blinded, randomized, placebo-controlled clinical trial, 72 women with polycystic ovaries were randomized to receive either 2 g of synbiotic sachet (n = 36) or placebo (n = 36) plus lifestyle modification. Fasting blood samples were taken before and after the intervention. FINDINGS Statistical analysis was performed in 60 participants with a mean (SD) age of 28.25 (5.98) years who completed the intervention (synbiotic group [n = 34] and placebo group [n = 26]). A significant mean (SD) decrease in C-reactive protein level was observed in the synbiotic group compared with the placebo group (-0.12 [9.57] v. -0.008 [4.69], P = 0.03). No significant differences in mean changes of lipid profile and atherogenic indexes were seen between the 2 groups. Although the estimated mean changes in atherogenic indexes in the synbiotic group indicates a greater reduction than the placebo group, no significant difference was detected. IMPLICATIONS Our 12-week synbiotic intervention improved the inflammatory status in women with polycystic ovaries without affecting lipid profile or atherogenic indexes.
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Affiliation(s)
- Zahra Hariri
- Clinical Nutrition and Dietetics Department, Faculty of Nutrition Sciences and Food Technology, National Nutrition and Food Technology Research Institute, Shahid Beheshti University of Medical Sciences Tehran, Tehran, Iran
| | - Zahra Yari
- Department of Nutrition Research, National Nutrition and Food Technology Research Institute, Faculty of Nutrition Sciences and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sedighe Hoseini
- Department of Obstetrics and Gynecology, Preventative Gynecology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Afsaneh Mehrnami
- Shahid Akbar-Abadi Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Khadijeh Abhari
- Department of Food Science and Technology, National Nutrition and Food Technology Research Institute, Faculty of Nutrition Sciences and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Golbon Sohrab
- Clinical Nutrition and Dietetics Department, Faculty of Nutrition Sciences and Food Technology, National Nutrition and Food Technology Research Institute, Shahid Beheshti University of Medical Sciences Tehran, Tehran, Iran.
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Sankhwar P, Jaiswar SP, Yadav S, Awasthi V, Goel A, Kumar P, Banik SP, Bagchi M, Bagchi D. Beneficial Effects of a Novel Fenugreek Seed Extract ( Trigonella foenum-graecum, Furocyst®) in Women with Polycystic Ovary Syndrome (PCOS): A Follow-up Compliance Clinical Investigation. JOURNAL OF THE AMERICAN NUTRITION ASSOCIATION 2023; 42:691-699. [PMID: 36441141 DOI: 10.1080/27697061.2022.2145526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 10/30/2022] [Accepted: 11/04/2022] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Polycystic Ovary Syndrome (PCOS) is an endocrine disorder which accounts for infertility around the world. The disease is characterized by elevated secretion of androgens in the women which results in enlargement of ovaries with accumulation of fluid filled cysts, irregular menstrual cycles, and hirsutism. This study reports the efficacy of a patented, standardized Trigonella foenum-graecum extract (Furocyst®) as an effective phytotherapeutic for effective management of PCOS. OBJECTIVE This randomized one-arm study assessed the efficacy of Furocyst® in 107 female volunteers over a period of 12 consecutive weeks. METHOD Following approvals of the Institutional Ethical Committee and clinicaltrials.gov, 107 female volunteers (age: 18-45 years) were recruited. Subjects consumed Furocyst® capsules (1,000 mg/day p.o.) over a period of 12 consecutive weeks. Physical (Sonographic scan, Hirsutism Score, Menstrual cycle, Body Weight, BMI, Height, Waist Circumference and Blood Pressure) and biochemical parameters (LH/FSH ratio, TSH, Prolactin, Fasting insulin, Fasting Glucose, triglyceride, cholesterol, HOMA Index, free and total testosterone, 2-hour GTT, DHEAS) were assessed at the beginning of the study as well as at intervals of 4 weeks till 12 weeks to determine the efficacy of Furocyst® on PCOS induced damage on reproductive and endocrine system. RESULTS Furocyst® treatment induced >40% reduction of mean cyst sizes in both ovaries with corresponding reduction of in ovarian volumes. LH:FSH ratio was also significantly improved with corresponding reduction in total testosterone and prolactin levels. As a result of improvement in endocrine function, menstrual cycle became regular in the subjects. Furocyst® also reduced the severity of other associated ailments such as insulin resistance, dyslipidemia, and improved liver function significantly. CONCLUSIONS This study reinstated the efficacy of Furocyst® as a safe phytotherapeutic to reverse the effects of PCOS inflicted damage on the female reproductive system without any adverse events.
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Affiliation(s)
- Pushplata Sankhwar
- Department of Obstetrics & Gynecology, King George's Medical University, Lucknow, India
| | - S P Jaiswar
- Department of Obstetrics & Gynecology, King George's Medical University, Lucknow, India
| | - Sonali Yadav
- Department of Obstetrics & Gynecology, King George's Medical University, Lucknow, India
| | - Vandana Awasthi
- Department of Obstetrics & Gynecology, King George's Medical University, Lucknow, India
| | - Apurva Goel
- Regulatory Department, Chemical Resources (CHERESO), Panchkula, India
| | - Pawan Kumar
- Research and Development Department, Chemical Resources (CHERESO), Panchkula, India
| | - Samudra P Banik
- Department of Microbiology, Maulana Azad College, Kolkata, India
| | - Manashi Bagchi
- Research & Development Department, Dr. Herbs LLC, Concord, California, USA
| | - Debasis Bagchi
- Department of Biology, Adelphi University, Garden City, New York, USA
- Department of Pharmaceutical Sciences, Texas Southern University, Houston, Texas, USA
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Polycystic Ovary Syndrome: A Brain Disorder Characterized by Eating Problems Originating during Puberty and Adolescence. Int J Mol Sci 2020; 21:ijms21218211. [PMID: 33153014 PMCID: PMC7663730 DOI: 10.3390/ijms21218211] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 10/27/2020] [Accepted: 10/28/2020] [Indexed: 02/07/2023] Open
Abstract
Polycystic ovary syndrome (PCOS) is an endocrine condition associated with reproductive and psychiatric disorders, and with obesity. Eating disorders, such as bulimia and recurrent dieting, are also linked to PCOS. They can lead to the epigenetic dysregulation of the hypothalamic-pituitary-gonadal (HPG) axis, thereby impacting on ovarian folliculogenesis. We postulate that PCOS is induced by psychological distress and episodes of overeating and/or dieting during puberty and adolescence, when body dissatisfaction and emotional distress are often present. We propose that upregulated activation of the central HPG axis during this period can be epigenetically altered by psychological stressors and by bulimia/recurrent dieting, which are common during adolescence and which can lead to PCOS. This hypothesis is based on events that occur during a largely neglected stage of female reproductive development. To date, most research into the origins of PCOS has focused on the prenatal induction of this disorder, particularly in utero androgenization and the role of anti-Müllerian hormone. Establishing causality in our peripubertal model requires prospective cohort studies from infancy. Mechanistic studies should consider the role of the gut microbiota in addition to the epigenetic regulation of (neuro) hormones. Finally, clinicians should consider the importance of underlying chronic psychological distress and eating disorders in PCOS.
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O'Brien B, Dahiya R, Kimble R. Hyperandrogenism, insulin resistance and acanthosis nigricans (HAIR-AN syndrome): an extreme subphenotype of polycystic ovary syndrome. BMJ Case Rep 2020; 13:e231749. [PMID: 32276996 PMCID: PMC7167451 DOI: 10.1136/bcr-2019-231749] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
HAIR-AN-a syndrome of hyperandrogenism (HA), insulin resistance (IR) and acanthosis nigricans (AN)-is a specific subphenotype of polycystic ovary syndrome (PCOS), and it is seen in almost 5% of all women with hyperandrogenism. An adolescent girl aged 11 years old was referred with adrenarche, hyperandrogenism and obesity commencing at age 8. Clinical and biochemical investigations confirmed significant hyperandrogenism and insulin resistance, and a diagnosis of HAIR-AN syndrome was made after exclusion of other differential diagnoses. HAIR-AN syndrome is an important diagnosis for the adolescent gynaecologist to be aware of, and it requires a multidisciplinary approach, including endocrinology input, for optimal management. Weight loss, lifestyle modification and combined hormonal pill and metformin are considered first-line treatment.
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Affiliation(s)
- Brooke O'Brien
- Paediatric and Adolescent Gynaecology, Department of Paediatric Surgery, Queensland Children's Hospital, South Brisbane, Queensland, Australia
- School of Medicine, The University of Queensland, St Lucia, Queensland, Australia
| | - Rachana Dahiya
- School of Medicine, The University of Queensland, St Lucia, Queensland, Australia
- Department of Endocrinology, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Rebecca Kimble
- Paediatric and Adolescent Gynaecology, Department of Paediatric Surgery, Queensland Children's Hospital, South Brisbane, Queensland, Australia
- Women's and Newborn Services, Royal Brisbane and Woman's Hospital Health Service District, Herston, Queensland, Australia
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Hachey LM, Kroger-Jarvis M, Pavlik-Maus T, Leach R. Clinical Implications of Polycystic Ovary Syndrome in Adolescents. Nurs Womens Health 2020; 24:115-126. [PMID: 32273076 DOI: 10.1016/j.nwh.2020.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 10/02/2019] [Accepted: 01/01/2020] [Indexed: 06/11/2023]
Abstract
Polycystic ovary syndrome (PCOS) is the most common endocrinopathy, affecting as many as 5% to 20% of women of reproductive age, depending on the diagnostic criteria applied. Features of PCOS include physiologic anovulation, hyperandrogenism, elevated luteinizing hormone, and increased gonadotropin-releasing hormone pulse frequency, which often manifest physically as acne and hirsutism. The clinical presentation of PCOS often mimics normal pubertal physiologic development, which may delay diagnosis and treatment of the condition in adolescent girls. A diagnosis of PCOS has life-long implications and is associated with increased risk for infertility, obesity, Type 2 diabetes, endometrial hyperplasia, uterine carcinoma, metabolic disorder, and cardiovascular disease. In this article, we provide an overview of clinical presentation, diagnostic criteria, health consequences, and current evidence-based clinical guidelines for the appropriate diagnosis and management of PCOS in adolescents.
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Screening and Management of the Hyperandrogenic Adolescent: ACOG Committee Opinion, Number 789. Obstet Gynecol 2020; 134:e106-e114. [PMID: 31568365 DOI: 10.1097/aog.0000000000003475] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Although androgen excess can manifest in many ways, the most common and recognizable symptoms are hirsutism and acne. Reports of hirsutism and acne should be taken seriously because of their possible association with medical disorders, their substantial effect on self-esteem and quality of life, and the potential for psychosocial morbidity. In patients with symptoms of androgen excess, the differential diagnosis should include physiologic hyperandrogenism of puberty, idiopathic hyperandrogenism, and polycystic ovary syndrome (PCOS). There is a great deal of overlap between the symptoms of PCOS and those of normal puberty, which makes the diagnosis of PCOS in the adolescent difficult. Treatment of acne and hirsutism should not be withheld during the ongoing longitudinal evaluation for possible PCOS. On physical examination, body mass index, blood pressure, and signs of hyperandrogenism, such as acne and hirsutism, should be evaluated. Although guidelines differ on recommended laboratory studies, most include measurement of total testosterone, free testosterone, or both, and screening for nonclassic congenital adrenal hyperplasia with a 17-hydroxyprogesterone test. Elevation of the free or total testosterone level higher than the adult female normative values is a key diagnostic feature of biochemical hyperandrogenism. Because treatment is indicated only when symptoms are distressing to the patient, the degree to which acne or hirsutism bothers the patient should be assessed. Before initiation of any medical therapy, expectations of treatment should be discussed with the patient. Anticipatory guidance is critical to help patients understand the timeline for expected responses to therapy.
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Medical Nutrition Therapy for Women With Polycystic Ovary Syndrome—Does One Size Fit All? A Narrative Review on Dietary Treatment for Adolescents and Young Adults. TOP CLIN NUTR 2020. [DOI: 10.1097/tin.0000000000000196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ravi SJ, Cree-Green M. Use of Successive Pharmacologic Hormone Suppression Testing for a Severe Presentation of Adolescent Polycystic Ovarian Syndrome: A Case Report. J Investig Med High Impact Case Rep 2019; 7:2324709619850215. [PMID: 31113263 PMCID: PMC6537283 DOI: 10.1177/2324709619850215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Pathological causes of acne and hirsutism include polycystic ovarian syndrome (PCOS), congenital adrenal hyperplasia, and adrenal or ovarian tumors. PCOS is largely a clinical diagnosis and often simple laboratory testing can rule out more severe pathology. In more severe cases, determination of the correct diagnosis can require hormone suppression testing. In this article, we present a full sequence of hormone suppression testing and workup necessary to arrive at the ultimate diagnosis. CASE PRESENTATION A 12-year-old normal weight (body mass index = 29th percentile), premenarchal female with Tanner III breast, Tanner V pubic hair presented with a 2.5-year history of severe hirsutism (Ferriman-Gallwey Score of 22), clitoromegaly, and deep voice. Successive hormone suppression and testing (ACTH stimulation testing, ovarian and adrenal imaging, dexamethasone-suppressed ACTH stimulation testing, and oral contraceptive therapy) was necessary to rule out congenital adrenal hyperplasia or a tumor and confirm PCOS. Metabolic testing, completed only after diagnosing PCOS, demonstrated insulin resistance. CONCLUSIONS This patient had an extreme presentation of a common disorder. Her premenarchal status, elevated androgens, and virilization raised concern for non-PCOS pathology requiring sequential pharmacological hormone suppression testing and imaging for accurate diagnosis and appropriate treatment. The testing presented here is not novel, but we present the full sequence of testing and clinical results. This full sequence is rarely necessary for accurate diagnosis given clinical presentation and initial evaluation and, therefore, to our knowledge, has not been published. All providers caring for patients with PCOS should be familiar with this testing and its interpretation for severe cases that warrant extra attention.
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The Effects of Synbiotic Supplementation on Metabolic Status in Women With Polycystic Ovary Syndrome: a Randomized Double-Blind Clinical Trial. Probiotics Antimicrob Proteins 2018. [DOI: 10.1007/s12602-018-9405-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Kim EJ, Jang M, Choi JH, Park KS, Cho IH. An Improved Dehydroepiandrosterone-Induced Rat Model of Polycystic Ovary Syndrome (PCOS): Post-pubertal Improve PCOS's Features. Front Endocrinol (Lausanne) 2018; 9:735. [PMID: 30564195 PMCID: PMC6288467 DOI: 10.3389/fendo.2018.00735] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 11/19/2018] [Indexed: 11/13/2022] Open
Abstract
Complete animal models investigating the pathogenesis and treatment of polycystic ovarian syndrome (PCOS) are not completely established. Although dehydroepiandrosterone (DHEA)-induced pre-pubertal rat model for PCOS has been widely used, the model exhibits weaknesses such as decreased ovary weight. Here, we report an innovative DHEA-induced PCOS model that addresses limitations of the pre-pubertal model. The 21-day-old (pre-pubertal) and 42-day-old (post-pubertal) female rats were subcutaneously injected with DHEA (60 mg/kg body weight) daily for up to 20-30 days. The post-pubertal model showed a steady increase in ovary weight and the number of ovarian cysts as well as uterine weight and thickness, which may be key features of PCOS, compared with the pre-pubertal model. Therefore, a post-pubertal PCOS model induced by DHEA may be an improved model to investigate the etiology of PCOS and development of therapeutic interventions.
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Affiliation(s)
- Eun-Jeong Kim
- Department of Science in Korean Medicine and Brain Korea 21 Plus Program, Graduate School, Kyung Hee University, Seoul, South Korea
- Department of Convergence Medical Science, College of Korean Medicine, Kyung Hee University, Seoul, South Korea
| | - Minhee Jang
- Department of Convergence Medical Science, College of Korean Medicine, Kyung Hee University, Seoul, South Korea
| | - Jong Hee Choi
- Department of Science in Korean Medicine and Brain Korea 21 Plus Program, Graduate School, Kyung Hee University, Seoul, South Korea
- Department of Convergence Medical Science, College of Korean Medicine, Kyung Hee University, Seoul, South Korea
| | - Kyoung Sun Park
- Department of Korean Medicine Obstetrics and Gynecology, College of Korean Medicine, Kyung Hee University, Seoul, South Korea
| | - Ik-Hyun Cho
- Department of Science in Korean Medicine and Brain Korea 21 Plus Program, Graduate School, Kyung Hee University, Seoul, South Korea
- Department of Convergence Medical Science, College of Korean Medicine, Kyung Hee University, Seoul, South Korea
- Institute of Korean Medicine, College of Korean Medicine, Kyung Hee University, Seoul, South Korea
- *Correspondence: Ik-Hyun Cho
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Cohen PR, Kurzrock R. Polycystic ovary syndrome in men. Med Hypotheses 2017; 103:64. [PMID: 28571814 DOI: 10.1016/j.mehy.2017.04.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Accepted: 04/19/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Philip R Cohen
- Department of Dermatology, University of California San Diego, San Diego, CA, United States.
| | - Razelle Kurzrock
- Center for Personalized Cancer Therapy and Division of Hematology and Oncology, Department of Medicine, University of California San Diego Moores Cancer Center, San Diego, CA, United States
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Panico A, Messina G, Lupoli GA, Lupoli R, Cacciapuoti M, Moscatelli F, Esposito T, Villano I, Valenzano A, Monda V, Messina A, Precenzano F, Cibelli G, Monda M, Lupoli G. Quality of life in overweight (obese) and normal-weight women with polycystic ovary syndrome. Patient Prefer Adherence 2017; 11:423-429. [PMID: 28280314 PMCID: PMC5338969 DOI: 10.2147/ppa.s119180] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE Polycystic ovary syndrome (PCOS) is characterized by phenotypic heterogeneity and has a wide variety of consequences. Approximately half of women with PCOS are overweight or obese, and their obesity may be a contributing factor to PCOS pathogenesis through different mechanisms. The aim of this study was to evaluate if PCOS alone affects the patients' quality of life and to what extent obesity contributes to worsen this disease. DESIGN To evaluate the impact of PCOS on health-related quality-of-life (HRQoL), 100 Mediterranean women with PCOS (group A), 50 with a body mass index (BMI) >25 kg/m2 (group A1) and 50 with BMI <25 kg/m2 (group A2), were recruited. They were evaluated with a specific combination of standardized psychometric questionnaires: the Symptom Checklist-90 Revised, the 36-Item Short-Form Health Survey, and the Polycystic Ovary Syndrome Questionnaire. The patients were compared with a normal-weight healthy control group of 40 subjects (group B). Another control group of 40 obese healthy women (group C) was used to make a comparison with PCOS obese patients (A1). RESULTS Our results showed a considerable worsening of HRQoL in PCOS patients (A) compared with controls (B). In addition, patients with PCOS and BMI >25 (A1) showed a significant and more marked reduction in scores, suggesting a lower quality of life, compared with controls (B) and with normal-weight PCOS patients (A2). CONCLUSION PCOS is a complex disease that alone determines a deterioration of HRQoL. The innovative use of these psychometric questionnaires in this study, in particular the PCOS questionnaire, has highlighted that obesity has a negative effect on HRQoL. It follows that a weight decrease is associated to phenotypic spectrum improvement and relative decrement in psychological distress.
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Affiliation(s)
- Annalisa Panico
- Department of Clinical Medicine and Surgery, University of Napoli Federico II, Naples, Italy
| | - Giovanni Messina
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
- Department of Experimental Medicine, Second University of Naples, Naples, Italy
- Correspondence: Giovanni Messina, Department of Clinical and Experimental Medicine, University of Foggia, Via L Pinto, 71122 Foggia, Italy, Tel +39 81 566 5804, Fax +39 81 566 5844, Email
| | - Gelsy Arianna Lupoli
- Department of Clinical Medicine and Surgery, University of Napoli Federico II, Naples, Italy
| | - Roberta Lupoli
- Department of Clinical Medicine and Surgery, University of Napoli Federico II, Naples, Italy
| | - Marianna Cacciapuoti
- Department of Clinical Medicine and Surgery, University of Napoli Federico II, Naples, Italy
| | - Fiorenzo Moscatelli
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Teresa Esposito
- Department of Experimental Medicine, Second University of Naples, Naples, Italy
| | - Ines Villano
- Department of Experimental Medicine, Second University of Naples, Naples, Italy
| | - Anna Valenzano
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Vincenzo Monda
- Department of Experimental Medicine, Second University of Naples, Naples, Italy
| | - Antonietta Messina
- Department of Experimental Medicine, Second University of Naples, Naples, Italy
| | - Francesco Precenzano
- Department of Mental and Physical Health, and Preventive Medicine, Child and Adolescent Neuropsychiatry Unit, Second University of Naples, Naples, Italy
| | - Giuseppe Cibelli
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Marcellino Monda
- Department of Experimental Medicine, Second University of Naples, Naples, Italy
| | - Giovanni Lupoli
- Department of Clinical Medicine and Surgery, University of Napoli Federico II, Naples, Italy
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