International Journal of Reproduction, Contraception, Obstetrics and Gynecology

Pitchai P et al. Int J Reprod Contracept Obstet Gynecol. 2016 Feb;5(2):470-476

www.ijrcog.org pISSN 2320-1770 | eISSN 2320-1789

DOI: http://dx.doi.org/10.18203/2320-1770.ijrcog20160393
Research Article

Awareness of lifestyle modification in females diagnosed with polycystic

ovarian syndrome in India: explorative study
Pothiraj Pitchai1*, S. R. Sreeraj2, Parmar Reema Anil3

1
Department of Community Physiotherapy, Maharashtra University of Health Sciences, Navi Mumbai, India
2
Department of Musculoskeletal Physiotherapy, Maharashtra University of Health Sciences, Navi Mumbai, India
3
Clinical Physiotherapist, Saxenas Physiotherapy clinic, Chembur East, Mumbai, India

Received: 28 December 2015

Revised: 31 December 2015
Accepted: 23 January 2016

*Correspondence:
Dr. Pothiraj Pitchai,
E-mail: pothirajpt@gmail.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Polycystic ovarian syndrome (PCOS) adversely affect women at varying stages of their life and
imperative to emphasis on prevention strategies since incidence of PCOS is on the rise. Study aims to explore
perception on PCOS, awareness on life style modification, emotional attributes, concern regarding PCOS and
utilization of physiotherapy services.
Methods: The study was conducted in Mumbai and Navi Mumbai, India. Self-made validated questionnaire was
administered. Descriptive analysis was done. Perception on PCOS, lifestyle modification, emotional attribution and
biggest concern were calculated as absolute frequencies and were reported as overall percentages. Chi square test was
applied on the demographic factor‘s influence on level of awareness.
Results: 21% of the respondents are very well aware about PCOS. 51% reported as doctor was their main source of
information about PCOS. 81% expressed that PCOS is manageable one. 62% aware that exercise helps in the
management of PCOS. Out of this, 39% are doing exercise on a regular basis. However all the study participants
reported, they have not had any consultation from physiotherapist for their structured exercise program.32% attributed
to anxiety after the diagnosis of PCOS. 64% of the respondents aware that changing in diet or eating habits can
influence in PCOS. However 95% of the subjects concurred to follow life style modification.
Conclusions: Efforts need to intensify in creating awareness on the general public about PCOS. Absolute majority of
the study participant uncoerced to follow lifestyle modification however emphasis needs to address on
multidisciplinary approach in managing PCOS.

Keywords: Polycystic ovarian syndrome, Awareness, Lifestyle modification, India

INTRODUCTION development of impaired glucose tolerance and

cardiovascular diseases furthermore it is a significant
Polycystic ovarian syndrome (PCOS) is a heterogeneous cause of distress to most women affected by it.2-7
clinical entity leading to development of metabolic,
endocrine and reproductive disorder. This multifaceted The pathogenesis of PCOS is complex and not
clinical manifestation comprises of hyperandrogenism, completely understood. The underlying hormonal
menstrual dysfunction, infertility, pregnancy imbalance is created by a combination of increased
complications and an increased prevalence of obesity and androgens and/or insulin. Genetic and environmental
abdominal obesity.1 PCOS enact as risk factors in contributors to hormonal disturbances with other factors

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including obesity, ovarian dysfunction and hypothalamic cyclicity, ovulation and fertility, reductions in
pituitary abnormalities are contribute to the etiology of testosterone levels and free androgen index.8
PCOS.8
This complex disorder affect both developed as well
PCOS women are at heightened risk of obesity, developing countries. Its prevalence ranges from 4%-
dyslipidemia and type II diabetes mellitus and may have 12% in general population of women in the world of
an increased risk of cardiovascular disorder because of reproductive age.22-28 Although there are no systemic
increased prevalence of subclinical atherosclerosis, studies from India, the observations by endocrinologists,
hyperlipidaemia, hypertension, inflammation and gynaecologists, dermatologists, etc. show a significant
endothelial dysfunction.8 It increases the risk of fetal rise in number of females with PCOS nevertheless
deformities, miscarriages, and complications during prevalence of PCOS in Indian adolescents estimated at
pregnancy including premature deliveries and neonatal 9.13%.29 As PCOS incidence is on the rise in India a
complications.9,10 PCOS also promotes psychological sense of urgency is needed in addressing this
morbidity including depression, poor body image and contemporary syndrome. Given the metabolic liabilities
self-esteem and reduced health related quality of life.11-13 of PCOS and an increase in the adaptation of sedentary
Thus PCOS is associated with short term and long term lifestyle and fast growing westernized diet culture in
presentations that may adversely affect women at varying India this study aims to explore perception on PCOS
stages of their life. Hence it is imperative in identifying among women with diagnosed PCOS, awareness on life
effective therapies for the prevention and treatment of the style modification, their concern regarding PCOS and
syndrome to reduce its health and economic burdens. utilization of physiotherapy services.

Lifestyle modification have been proposed to improve METHODS

not only metabolic and reproductive manifestation of
PCOS but also yielding benefits including improvements This is a cross sectional study conducted between the
in mood, self-esteem, anxiety, depression and years of December 2014-May 2015. Subjects were
psychological well-being.14-17 Lifestyle modification is recruited through purposive sampling method with the
the preferred first-line treatment for PCOS. The role and sample size of 100 who were visiting gynaecological
the effect of lifestyle modification are well documented clinics in and around Mumbai and Navi Mumbai, India.
in the literature. These non-pharmacological measures Women who was diagnosed as PCOS by a gynaecologist
such as Diet and exercise are recommended as first-line and reproductive age group between 18-35 years were
of treatment in oligomenorrhea, hirsutism, infertility, and only included in this study. Institutional ethical
obesity in PCOS by the majority of endocrinologists and committee approval was obtained. Participants were
gynaecologists.18 Lifestyle modification, focus on dietary explained about purpose of study and obtained their
modification and increased physical activity and Consent. Self-made questionnaire was developed and
behavioural therapy, considered as important aspect in validated from specialist in this field. To suite cultural
the management of PCOS.19 Physical exercises have been differences Questionnaire was translated from English to
widely known to induce oxidative metabolism in tissues Hindi with the help of linguistics. This self-made
and the oxidative metabolism of the ovary is a stimulant questionnaire then was circulated among the participants.
for follicular development. Components of questionnaire consist of demographic
details, Perception of PCOS, Awareness of exercise in
Maiya et al, 2008 stated, since weight loss by physical PCOS, Emotions attributed to PCOS, Biggest concern
activity doesn‘t have potential side effects it should be with PCOS and willingness in Lifestyle modification. Chi
addressed as first line of treatment. Graded aerobic square test was applied on the demographic factor‘s
exercise is a definite tool in decreasing the body weight influence on level of awareness P<0.05 was considered
in obese infertile women with PCOS also helps in statistically significant and descriptive statistics was done
reducing the cyst size, increasing the ovulation, and by using SPSS Statistical Software version 17 (SPSS Inc.,
pregnancy rate.20 It is well known that exercise training Chicago, IL, USA).
improves an array of health-related outcomes, including
protection against the development of Coronary Vascular RESULTS
Disease and diabetes, reduced morbidity and mortality
also elevates psychological benefits.8 Wahrenberg et al in 100 unique, complete responses to the questionnaire were
1999 suggested a minimal amount of weight loss (5– analyzed. Mean age of PCOS population were 23.38±4.6.
10%) over as little as 4 weeks is sufficient to improve the Total 9% of study participants were between age group of
presentation of PCOS.21 Weight loss is thus a desirable 30-35 years, 21% were25-30 and remaining 70% equally
outcome in overweight women with PCOS for treating distributed in 21-25 as well 18-20 years. 51% of the
both acute clinical and long-term metabolic health. subjects were students, 23% belongs to professional,
Weight loss via energy restriction reinforce in the housewife accounting for 14%, 7% house maid and 5%
reductions in abdominal fat, blood glucose, blood lipids, were unemployed.
and insulin resistance, improvements in menstrual

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 Pitchai P et al. Int J Reprod Contracept Obstet Gynecol. 2016 Feb;5(2):470-476

In level of awareness, 21% of the respondents indicated opted to family and 4% shared Physiotherapist and
they had been informed well about PCOS and were very friends individually as their source of information.
aware of it, 46% reported as somewhat aware, while 27% Majority participant of 81% expressed that PCOS is
said minimally aware and 6% of them considered manageable one. When asked about awareness on
themselves as not at all aware. The influence of age on treatment option available for PCOS, 93% responded as
the level of awareness is not significant (p = 0.376) positive and 7% reported for negative response.
whereas association of occupation was highly significant Distribution of positive response frequency on the
(p =0.014).These influence of demographic factors on the treatment option is shown in Figure 1. Only 84% of the
level of awareness is shown in Table 1. Main source of participant was currently undergoing treatment and
information about PCOS was Doctor, Internet and Media details of it shown in Figure 2.
which account for 51%, 22%, 14% respectively. 5 %

Table 1: Impact of demographic factors on level of awareness using Chi-square test (p values set at p<0.05).

p- Age Group Level of Occupation p-

Value Awareness Value
30-35 25-30 20-25 17-20 Student House- Un- Professional House-
maid employed wife
0.0% 4.8% 2.8% 11.8% Not at all 2.2% 25.0 16.7% 3.8% 6.7%
%
44.4% 42.9% 25.0% 14.7% Minimally 13.3% 37.5 33.3% 34.6% 46.7%
aware %
44.4% 38.1% 47.2% 50.0% Somewhat 60.0% 37.5 33.3% 26.9% 46.7%
aware %
11.1% 14.3% 25.0% 23.5% Very aware 24.4% 0.0% 16.7% 34.6% 0.0%

Table 2: Frequency distribution of feelings attributed to diagnosis of PCOS by each age group.

No of Respondents
Age
Anxiety/
Group Depression/sadness Frustration Embarrassment Hopelessness Indifferent Others
worried
17-20 21 8 6 8 5 4 1
20-25 22 12 15 5 4 6 0
25-30 7 10 3 5 7 3 0
30-35 2 1 2 3 1 2 0

of exercise helps in PCOS, 39% are reported as doing

Treatment Option for PCOS exercise on a regular basis and their adopted exercise
50 45 shown in Figure 3 where as 61% citing the reasons that
refrains from doing exercise is shown in Figure 4. All
IN PERCENTAGE

40 study participants reported that they have not had any

30 24 consultation from physiotherapist for their structured
20 exercise despite 42% believed that exercise helps in
20 11 weight reduction, 26% thought exercise helps in
10 menstrual irregularity and their distribution is showed in
0 Figure 5.
Medication Lifestyle Exercise Surgery
Modification In Distribution of emotional feelings towards PCOS,
anxiety placed on top followed by depression which
secured 32%, 19% respectively. Number of multiple
Figure 1: Availability of treatment option for PCOS.
responses obtained in each category according to age
group is shown in table 2. Irregular periods and weight
62% aware that exercise helps in the management of
gain being their major concern in PCOS which
PCOS and their source of awareness majorly from their
demonstrated in Figure 6. However when analysed by
gynaecologist, internet and media which hold for 44%,
each age group above mentioned remain constant except
19% and 16% respectively. In subjects who were aware

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 Pitchai P et al. Int J Reprod Contracept Obstet Gynecol. 2016 Feb;5(2):470-476

the age group of 25-30 who opted for difficulty in

pregnancy followed by irregular period. 50 42 Benefits of Exercise

IN PERCENTAGE
40 26
64% of the respondents aware that changing in diet or 30
20 14
eating habits can influence in PCOS out of which 46% 5 7 2 4
10
altered their diet composition, 30% reduced their energy 0
or calorie intake, 17% on Weight maintenance regime
and 7% said they increased physical activity. However
95% of the subjects concurred to follow life style
modification besides their fertility drug and oral
contraceptive pills.

Undergoing type of Treatment

Figure 5: Benefits which can be obtained by doing
40 37 exercise.
IN PERCENTAGE

30
18 Concern regarding PCOS
20 15 15
11
35 30
10 4 28

IN PERCENTAGE
30
0 25 20
Medication Medication Medication Hormonal Diet Exercises
for for IR for Theraphy 20
infertility acne/excess
15
13
hair growth
10
8
5 1
Figure 2: Treatment undertaken by the participants. 0
Difficulty in Irregular Abnormal Weight gain Acne Others
pregnancy periods hair growth

Opted Exercise
40 35 Figure 6: Biggest concern of PCOS by the
IN PERCENTAGE

participants.
30 26
21 DISCUSSION
20
9 On the perception of PCOS, this study demonstrate 21%
10 6 of the participant were ‗very aware‘ especially in the age
3
group of 21-25 which comprised of professionals.
0 Whereas 6% were not at all aware as they were
Walking Jogging Cycling Resisted Yoga Others
excercises unemployed/housemaids and also not much educated. A
study by E Scott et all in reports that out of 657
participants more than 50% were completely aware about
Figure 3: Exercise opted by the participants. PCOS and according to his study physician was the main
source of information among 63.5% whereas this study
Refrain factors for Exercise shows 51% which signifies physician plays an important
role in imparting knowledge about PCOS.30 21% opted
40 33 for Internet for their knowledge about PCOS as 45%
IN PERCENTAGE

samples were students and 26% professionals. Data

30 25 shows that 19% of people thought PCOS is not
19 17 manageable due to loss of hope in some situations or due
20
to no improvement in their condition, indifference about
10 6 trying to manage or treat it and lacks of knowledge as
some of them are uneducated. 7% were unaware of
0 different treatment options available as no source of
Lack of time Lack of Lack of Not interested Mood swings
place/location proper / indifference awareness about the same was made available to them
knowledge
being illiterate. Emotional disturbances and difference in
attitude influenced 16% of the participant who did not
Figure 4: Refraining factors from doing exercise. undergo any kind of treatment as they were indifferent
about the condition or had given up on trying as they saw
no improvement and some were depressed and lost hope

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 Pitchai P et al. Int J Reprod Contracept Obstet Gynecol. 2016 Feb;5(2):470-476

of it being further treated. Out of 84% who were exercise training improves an array of health-related
currently undergoing treatment 20% indulged in some outcomes not only physical also psychological well-being
sort of exercise and majority belongs to students. which includes protection against the development of
cardio vascular disease and insulin sensitivity.33-36 Arun
However this study reveals 62% aware about exercise Maiya et al in reported that the graded aerobic exercise
which helps in PCOS and source being gynaecologist; helps in reducing the cyst size, increasing the ovulation,
however out of these only 39% exercise regularly and pregnancy rate as compared to control group. A study by
most of them have started exercising recently in spite of Nidhi R et al in observed holistic yoga program in PCOS
being diagnosed more than a year. This is because it took helps in reducing anxiety symptoms.37 Physiotherapist are
some time for the subjects to analyse and try to adhere to directly not only involved in exercise testing but also
a specific type of treatment. Nevertheless 35% of them prescribing tailor made exercise program based on the
preferred only walking due to lack of time to do any other patient needs and functional impairment. Absence of
form of exercise but none followed any protocols for the physiotherapist‘s contribution in the comprehensive
same exercise. Despite of being aware of exercise that management of PCOS is beyond the scope of this study.
helps in managing PCOS 61% of the subjects were not However participant‘s knowledge on PCOS having high
exercising regularly especially professionals and students proximity to their gynaecologist and /or physician.
cited due to lack of time followed by lack of knowledge Physiotherapists need to bridge this gap by joining hands
amongst housemaid, unemployed also students. with medical practitioner in patient education, motivating
them to adhere regular physical activity apart from need
Emotional well-being of the subject with PCOS is well based exercise program and add evidence to the literature.
established in the past. E Scott et al study exhibits 66.5% Even academician need to inculcate evidence based
attributed frustration to PCOS whereas this study reveals practice of PCOS at an undergraduate physiotherapy
32% feel anxious as they are not completely aware of program to improve demand supply ratio. This
what PCOS is and will they ever be able to manage it. contemporary PCOS demands of multidisciplinary
19% feel depressed as the distorted body image and approach emphasis need to be placed on the life style
altered quality of life hinder their mental state due to modification as well. Furthermore this study can be
hormonal alterations slipping them into depression in explored identifying barriers in lifestyle modification also
PCOS. the effects of lifestyle modification in PCOS.

In contrast to E Scott et al major concern of this study CONCLUSIONS

participants being irregular period and weight gain,
particularly among the students in the age group between Efforts need to intensify in creating awareness on the
17-25 years, which affects emotional status and physical general public about PCOS since more than 30% of the
appearance. Infertility, second major concern, particularly participants reported as ―minimally aware‖ and ―not at all
observed in females 25-30 years of age, as getting aware‖ especially develop a strategy to reach to the lower
married and having children is a priority to Indians, and socioeconomic strata. Irregular periods and weight gain
motherhood is a defining factor in a woman‘s status with was the major concern of our study participants and
the family and in social circles.31,32 majority of them are anxious. Absolute majority of the
study participants uncoerced to follow lifestyle
64% of the respondents aware that changing in diet or modification however physiotherapist need to work along
eating habits can aid in PCOS out of which 88% altered with the medical practitioner to sensitize PCOS
their diet primarily in diet composition. Though aware in population and prescribe need based structured exercise
diet modification 12% participants did not modify their program for the better outcome. Hence this multifaceted
diet because they found it difficult to restrain to the diet, presentation signifies need of multidisciplinary approach.
not interesting enough also, dieting takes a long time to
show improvement and requires patience and ACKNOWLEDGEMENTS
perseverance which today's generation lacks in. 95% of
the subjects concurred to follow life style modification We are very thankful to all our participants who made our
besides their fertility drug and oral contraceptive pills that research possible. Grateful to the department of
clearly indicates a need of multidisciplinary approach in Biostatistics at our Institute for facilitating data analysis.
managing PCOS involving medical and allied health Thankful to the almighty for providing immense strength
professionals focusing on physical and psychological to conduct this study.
well-being of subjects with PCOS.
Funding: No funding sources
100% of this study participant reported that they had not Conflict of interest: None declared
received any structured exercise program from any Ethical approval: The study was approved by the
physiotherapist. This may be due to the fact that subjects Institutional Ethics Committee
were not aware that physiotherapist are involved in
exercise prescription neither had been advised to consult
however high level of evidence affirms structured

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 Pitchai P et al. Int J Reprod Contracept Obstet Gynecol. 2016 Feb;5(2):470-476

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