Polycystic Ovary Syndrome - E-Book: Basic Science to Clinical Advances Across the Lifespan

Front Cover
Inside front cover
Polycystic Ovary Syndrome
Copyright
Contributors
Foreword
Preface
Dedication
Acknowledgment
Table of Contents
SECTION I Overview of Polycystic Ovary Syndrome
	1 Introduction to polycystic ovary syndrome
		Introduction
			Health issues of polycystic ovary syndrome
			History of polycystic ovary syndrome
			Definition
				The discourse on the definition of polycystic ovary syndrome
			Prevalence of polycystic ovary syndrome
		References
	2 Polycystic ovary syndrome phenotypes
		Introduction
		Ethnic variations in PCOS prevalence and clinical presentation
			Evolution of diagnostic criteria
				The four phenotypes
				Phenotypes A and B
				Phenotype C
				Phenotype D
			Insulin resistance in PCOS phenotypes
			Differences in risk of metabolic complications and cardiovascular disease among phenotypes
			Differences in impact on fertility
			Therapeutic approach based on phenotypes
		References
	3 Polycystic ovary syndrome in adolescents
		Introduction
		Risk factors and pathogenesis of PCOS in adolescents
		Diagnostic challenges in adolescent PCOS
			Immaturity of the hypothalamic-pituitary-axis and menstrual irregularities
			Hyperandrogenism
			Physiologic insulin resistance and additive effects of obesity in PCOS adolescents
		Differential diagnosis of PCOS in adolescents
		Diagnosis of PCOS in adolescence
		Clinical presentation
			Oligo/anovulatory dysfunction
			Clinical signs of hyperandrogenism
				Hirsutism
				Acne
				Alopecia
				Obesity and insulin resistance
					The role of IR and markers of metabolic syndrome in the diagnosis of PCOS
				Acanthosis nigricans
		Quality of life in adolescents with PCOS
		Diagnostic approach to PCOS in adolescence
			Laboratory testing for biochemical hyperandrogenism
			Ultrasonography
		Treatment strategies
			Lifestyle interventions
			Combined oral contraceptive pills
			Antiandrogens
			Insulin sensitizers
				Metformin
				Thiazolidinediones
				Combination treatment
			Antiobesity treatment (bariatric surgery)
			Contraception
			Management of dermatologic manifestations
		Summary
		References
SECTION II Pathogenesis and Clinical Presentation
	4 Pathophysiology of polycystic ovary syndrome
		Pathophysiology of polycystic ovary syndrome
		Hormonal aberrations
			Androgen excess
				Functional ovarian hyperandrogenism
				Hypothalamic-pituitary-ovarian axis dysregulation
				Functional adrenal hyperandrogenism
			Insulin resistance and hyperinsulinemia
		Vascular endothelial growth factor
		Vitamin D
		Epigenetics
			MicroRNAs
			DNA methylation
		Genetics
		References
	5 Interplay of adipocytokines with polycystic ovary syndrome
		Introduction
		Adiponectin
		Leptin
		Resistin
		Visfatin
			Apelin
			Omentin
		Chemerin
		Asprosin
		Conclusion
		References
	6 Crosstalk between oxidative stress and chronic inflammation in pathogenesis of polycystic ovary syndrome
		Introduction: The role of oxidative stress and chronic inflammation in the pathogenesis of polycystic ovary syndrome
		The oxidant and antioxidant system
		Oxidative stress and chronic inflammation
		Oxidative stress and polycystic ovary syndrome
		Effects of reactive oxygen species on cellular functions in polycystic ovary syndrome patients
			Transcription factor activation
			Protein kinase activation
			Ion channel opening
			Protein oxidation
			Lipid peroxidation
		Oxidative stress biomarkers detected in polycystic ovary syndrome
			Malondialdehyde
			Nitric oxide
			Advanced glycation end products
			Xanthine oxidase
			Total antioxidant capacity
			Superoxide dismutase
			Glutathione peroxidase
			Vitamin E
		Identification and prevention of OS enhancing factors
		Conclusion
		References
	7 Polycystic ovary syndrome and subfertility: Ovulation dysregulation and fertility problems (clinical features and pathophysiology)
		Introduction
		Normal ovulation physiology
			Hormones involved in ovulation
		Pathology in polycystic ovary syndrome
			Hypothalamic: Pituitary axis
			At the level of ovaries
			Obesity and insulin resistance
			At the level of endometrium
			Intrauterine exposure of androgens
			Other factors
		Conclusion
		References
	8 Clinical features and presentation of polycystic ovary syndrome
		Introduction
			Clinical features of polycystic ovary syndrome: A brief overview
		Clinical features
			Cutaneous manifestations
				Hirsutism
				Acne
				Androgenic alopecia
				Acanthosis nigricans
				Seborrhea
			Ovulatory dysfunction
				Oligomenorrhea
				Infertility
			Metabolic dysfunction
				Obesity
				Insulin resistance
				Dysglycemia in polycystic ovary syndrome
			Psychological vulnerability
			Other associations of polycystic ovary syndrome
				Thyroid dysfunction
				Endometrial carcinoma
				Lipid disorders
				Obstructive sleep apnea
				NAFLD/NASH
				Adverse pregnancy outcomes
		References
	9 Diagnostic criteria for polycystic ovary syndrome
		Introduction
		Diagnosis of polycystic ovary syndrome in adults
			Clinical features
				Menstrual dysfunction
					Menstrual irregularities
					Gonadotropin effects
					Endometrial dysplasia and cancer
				Ovarian dysfunction
					Ovarian morphology and role of ultrasound
					Ultrasound criteria for polycystic ovary syndrome
					Ovarian follicular defects
					Anovulatory infertility
				Hyperandrogenism (clinical evaluation)
					Hirsutism
					Acne
					Virilization
			Biochemical testing in polycystic ovary syndrome
				Tests in females with normal menstrual cycles
				Tests in females with oligomenorrhea
				Tests in females on pharmacotherapy
				Tests in females with features of other endocrine disorders
			Diagnostic criteria
				Rotterdam criteria
		National institutes of health criteria
		Androgen excess and polycystic ovary syndrome society criteria
		Diagnosis of polycystic ovary syndrome in postmenopausal females
			Postmenopausal androgens
			Clinical presentation
		Diagnostic criteria
		Diagnosis in adolescents
			Clinical presentation
				Hirsutism
				Acne
		Challenges in the diagnosis of polycystic ovary syndrome in adolescents
		Diagnostic criteria in adolescents
			Differential diagnosis
				Nonclassic congenital adrenal hyperplasia
				Androgen-secreting tumors/ovarian hyperthecosis
				Other causes
			Differentials to consider in adolescents
				Physiologic adolescent anovulation
				Virilizing/classic congenital adrenal hyperplasia
				Congenital disorders of adrenal steroid metabolism or action
				Insulin-resistance disorders
				Idiopathic hyperandrogenism
		Referral to specialist
			Follow-up
				Cardiometabolic review
				Review of reproductive outcomes
		Conclusion
		References
	10 Polycystic ovary syndrome and metabolic syndrome: Risks in later life
		Introduction
		Polycystic ovary syndrome and obesity
		Polycystic ovary syndrome and insulin resistance
		Assessment of insulin resistance
			Hyperinsulinemic euglycemic clamp technique
			Surrogate markers of insulin resistance
			Novel biomarkers
		Polycystic ovary syndrome and metabolic syndrome
			Ethnic differences in risk of metabolic syndrome
			Metabolic disturbances in nonobese females with polycystic ovary syndrome
			Combined oral contraceptive COC use and risk of metS in PCOS
			Association of vitamin D deficiency with metabolic markers in PCOS
			Hyperandrogenism and risk of metabolic syndrome
		Metabolic syndrome and polycystic ovary syndrome phenotype
		Abnormalities of glucose tolerance and diabetes in polycystic ovary syndrome
			Association of body mass index with glucose abnormalities
			Risk of incident glucose abnormalities on longitudinal studies
			Determining glucose abnormalities
		Risks in later life
		Screening for metabolic syndrome
			History
			Physical assessment and laboratory assessment
		Clinical implications
		Future research needs
		References
	11 Polycystic ovary syndrome and mental health
		Introduction
		Depressive and anxiety disorder
		Body image and polycystic ovary syndrome
		The complex trio of culture, stigma, and polycystic ovary syndrome
		Sexuality and marital life
		Quality of life
		Coping strategies
		Eating disorders
		Bipolar affective disorder
		The complex relationship between obesity, polycystic ovary syndrome, and psychological issues
		Management of polycystic ovary syndrome
			Psychoeducation
			Treatment of the primary condition is cardinal to the outcome of the illness
			Screen for psychiatric disorders
			Lifestyle modifications
			Psychotherapy
			Cognitive behavioral therapy
		Specific management for anxiety and depressive disorders
		Specific biologic interventions for mood disorder in polycystic ovary syndrome
		Referral to specialized psychiatric services
		Conclusion
		References
	12 Polycystic ovary syndrome and nonalcoholic fatty liver disease
		Is there any link between polycystic ovary syndrome and nonalcoholic fatty liver disease?
		What is the plausible connection between polycystic ovary syndrome and nonalcoholic fatty liver disease?
			When to suspect and who to screen
			How to diagnose nonalcoholic fatty liver disease
			Options we have in the toolbox to treat
				Lifestyle modification
				Insulin-sensitizing agents
			Complications and prognosis
				Liver-related complication
				Other complications
		Conclusion
		References
	13 Male polycystic ovary syndrome equivalent
		Introduction
		Findings in male relatives of females with PCOS
			Cardiovascular disease and other risks in PCOS patient relatives
		Early-onset androgenic alopecia: A possible male PCOS equivalent marker?
			Background and studied nature of the condition
				Sex hormone–binding globulin as an important marker
				Circulating androgen levels and sex differences
			Risks associated with AGA
				Cardiovascular disease and metabolic syndrome risks
				Risk of compromising male fertility
				Prostate-related risks
		Conclusions and final remarks
		References
SECTION III Management of Polycystic Ovary Syndrome and Associated Comorbidities
	14 Pharmacologic management of PCOS: Menstrual irregularities
		Definition
			Incidence
		Pathophysiology
			Effects of gonadotropic-releasing hormones
				Neuropeptide: Kisspeptin
			Ovarian hormones that regulate the action of GnRH neurons
				Androgen
				Anti-Müllerian hormone
			Metabolic regulation of gnrh production
				Insulin resistance
				Obesity
		Implications of menstrual irregularities in PCOS patients
		Management of menstrual irregularities in polycystic ovary syndrome
			First-line management
				Weight reduction/lifestyle modifications
			Hormonal treatment
				Oral contraceptive pills
					Estrogen component of oral contraceptive pills
				Progesterone
					Progesterone-only hormonal treatment
			Second-line pharmacologic treatment
				Insulin sensitizers
					Metformin
					Inositol
					Metformin with LSM and COCP
					COCP with antiandrogen
		Summary
		References
	15 Pharmacologic management for polycystic ovary syndrome: Hirsutism and acne
		Introduction
		Treatment of hirsutism
			Cosmetic and direct hair removal measures
			Medical therapy
				Topical therapy
				Systemic therapy
					Combination oral contraceptives
					Antiandrogens receptor antagonist
					Spironolactone
					Cyproterone acetate
					Flutamide
					Finasteride
		Treatment of acne vulgaris
			Topical therapy
				Topical retinoids
				Topical antibiotics
				Topical dapsone
				Azelaic acid
		Systemic therapy
			Systemic antibiotic
			Hormonal therapy
				Estrogens and progestins
				Androgen receptor blockers
				Spironolactone
			Oral isotretinoin
			Oral zinc
		Devices and physical modalities for treating active acne
		Conclusion
		References
	16 Pharmacologic management for polycystic ovary syndrome: Weight loss
		Significance of weight in polycystic ovary syndrome
		Weight management
			Lifestyle modification strategies
			Dietary management
			Physical activity
			Behavior modification
		Pharmacologic interventions
			Glucagon-like peptide-1 agonists (liraglutide and semaglutide)
			Combination of phentermine and topiramate
			Combination of naltrexone and bupropion
			Orlistat
		Bariatric surgery
		References
	17 Role of insulin sensitizers in the management of polycystic ovary syndrome
		Introduction
		Mechanism of insulin sensitizers in PCOS
		Insulin sensitizers in polycystic ovary syndrome
			Metformin
				Mechanism of action
				Clinical effects
					Effect on androgens
					Menstrual irregularity and clinical hyperandrogenism
					Fertility and live birth rate
					Insulin insensitivity and hyperinsulinemia
					Glucose intolerance
					Body weight and composition
					Dyslipidemia and cardiovascular disease
				Dose and side effects
			Thiazolidinediones
				Mechanism of action
				Metabolic and endocrine effects
				Side effects
			Glucagon-like peptide 1 agonists
				Mechanism of action
				Metabolic effects and endocrine effects
				Side effects
			Miscellaneous agents
		Comparative studies among various insulin sensitizers
		Conclusion
		References
		Reading list
	18 Cardiovascular risk reduction in polycystic ovary syndrome
		Background
		Cardiovascular risk factors in polycystic ovary syndrome
			Hypertension and polycystic ovary syndrome
			Obesity, metabolic syndrome, and polycystic ovary syndrome
			Insulin resistance, diabetes mellitus, and polycystic ovary syndrome
			Dyslipidemia and polycystic ovary syndrome
		Polycystic ovary syndrome and cardiovascular diseases
			Clinical cardiovascular disease
			Subclinical cardiovascular disease
		Cardiovascular risk management in polycystic ovary syndrome
		Primary prevention strategies for cardiovascular disease risk reduction in patients with polycystic ovary syndrome
			Lifestyle changes
			Medical therapy
		Conclusion
		References
	19 Management of subfertility in polycystic ovary syndrome
		Introduction
		Physiologic principles of gonadotrophin ovarian stimulation
			Follicle-stimulating hormone threshold/window concept
			Luteinizing hormone role in folliculogenesis
			Anti-müllerian hormone and folliculogenesis
		Pathophysiology: The effect of polycystic ovary syndrome on fertility
		Investigations of infertility patients in polycystic ovary syndrome
		Principles of management of anovulatory infertility in polycystic ovary syndrome
		Management therapies
			Improving insulin resistance
				Lifestyle modifications and weight loss
				Insulin-sensitizing agents
					Metformin
					Myoinositol
				Other insulin-reducing therapies
			Improving follicle-stimulating hormone/luteinizing hormone levels
				First-line therapy
					Clomiphene citrate
					Mechanism of action.
					Selection of patients.
					Dose.
					Monitoring.
					Ovulation trigger and luteal phase support.
					Efficacy of clomiphene citrate.
					Safety of clomiphene citrate.
					Clomiphene citrate resistance and failure.
					Aromatase inhibitors
					Mechanism of action.
					Dose.
					Comparison of letrozole and clomiphene citrate.
					Tamoxifen
				Second-line therapy
					Gonadotrophins
					Prerequisites for therapy.
					Mechanism of action.
					Choice of gonadotrophins.
					Gonadotrophin protocol for PCOS patients.
					The chronic low-dose, step-up protocol.
					The step-down protocol.
					The sequential protocol.
					Monitoring of the treatment.
					Counseling of the patient.
					Combined oral and parenteral ovulation induction treatments.
					Risks of gonadotropin treatment.
					Multiple pregnancy.
					Ovarian hyperstimulation syndrome.
					Malignancy.
					Surgical ovulation induction
					Laparoscopic ovarian drilling (LOD).
					Method.
					Mechanism of action.
					Side effects.
					Advantages of laparoscopic ovarian drilling.
					Predictors of success.
					Transvaginal hydrolaparoscopy (THL).
					Intrauterine insemination (IUI).
				Third-line management
					In vitro fertilization
		Conclusion
		References
	20 Management of associated risks of pregnancy in polycystic ovary syndrome
		Possible underlying mechanism of pathophysiologic changes in females with PCOS during pregnancy
			PCOS phenotypes
			Effects of insulin resistance
			Effects of obesity and gestational weight gain
			Effect of inflammation
			Effect of infertility and multiple pregnancy
		Risks associated with pregnancy in polycystic ovary syndrome
			Early pregnancy loss
			Gestational diabetes mellitus
			Hypertensive disease in pregnancy
			Preterm birth
			Small for gestational age fetus
		Management of pregnancy complications in polycystic ovary syndrome patients
		Lifestyle modifications
		Metformin
		Myoinositol
		Conclusion
		References
	21 Importance of lifestyle modifications
		Introduction
		How lifestyle interventions work
			Pathophysiology/mechanism
		Diet modification
		Exercise
		Behavioral strategies
		Vitamin D
		Environmental endocrine disruptors
		Summary
		References
	22 Role of complementary and alternative medicine in polycystic ovary syndrome
		Introduction
		Etiology
			Hyperandrogenism
			Hyperinsulinemia
		Treatment modalities
			Conventional treatment approaches
			Complementary approaches
		Complementary and alternative medicine
			Role of phytoconstituents and vitamins in the management of PCOS
				Resveratrol
			Flavones and flavonoids
			Vitamin C
			Vitamin E
			Vitamin D
			Fatty acid
		Role of medicinal herbs in the management of PCOS
			Wild indigo (Tephrosia purpurea)
			Aniseed (Pimpinella anisum)
			Pergularia (Pergularia daemia)
			Aloe vera (Aloe barbadensis)
			Atractylodes (Atractylodes macrocephala koidz)
			Guggul (Commiphora wightti)
			Mistletoe fig
			Licorice (Glycyrrhiza glabra)
			Peppermint (Mentha piperita)
			Ginseng (Panax ginseng)
			Puncture vine (Tribulus terrestris)
			Gymnema (Gymnema sylvestre)
			Lodh tree (Symplocos racemosa)
			Chaste tree (Vitex negundo)
			Licogliflozin
			(L.) roxb. (Caesalpinia bonduc)
			Humanin
		Role of functional foods in the management of PCOS
			Soy isoflavone (Glycine max)
			Turmeric (curcumin)
			Onion (Allium fistulosum)
			Flaxseed (Linum usitatissimum)
			Pomegranate (Punica granatum)
			Cinnamon (Cinnamomum zeylanicum)
		Role of nuts intake in the management of PCOS
			Hazelnut
			Walnut
			Almond
		References
	23 Evidence-based recommendations for clinical practice (future directions: Research and practice)
		Introduction
		Questions for investigating and establishing quality standards for the diagnosis of PCOS
		Questions for understanding what works for improving treatments and interventions for PCOS
		Questions for identifying the mental and physical health comorbidity associated with PCOS
		Questions for exploring the contextual and social factors related to PCOS outcomes
		Questions for strengthening capacity building and organizational readiness for health systems responsive to the needs of Populations With or at Risk for PCOS
		Concluding remarks
		References
SECTION IV Global Approach to Polycystic Ovary Syndrome
	24 Polycystic ovary syndrome in South Asians
		Genetics of PCOS in the South Asian population
		Metabolic disorders and other medical conditions in South Asians with PCOS
		PCOS fertility and pregnancy
		Physical characteristics of PCOS in South Asian females with PCOS and the impact on quality of life
		References
	25 Situation analysis of polycystic ovary syndrome in Central and East Asia
		Understanding polycystic ovary syndrome in the region
			Prevalence
		Factors influencing the prevalence, diagnosis, and management of PCOS
			Ethnicity
			Lifestyle behavior and food habits of PCOS patients
		Central Asia
			The healthcare system in Central Asia
				Health-seeking behaviors
				Prevalence of PCOS and women’s health
				Lifestyle behaviors
				Impact of culture on health-seeking behavior
				Psychological impact
		East Asia
			China
				Factors influencing the prevalence, diagnosis, and management of PCOS in China
					Ethnicity
					Health systems
					Types of healthcare
					Chinese health beliefs and their impact on healthcare
					Health beliefs that have impacted the minds of health educators
					Health-seeking behaviors of the older cohort of the Chinese population and how they impact the health behaviors of families
					Health risk behaviors of the older cohort
					Food culture
					Foods to be avoided in PCOS.
					Foods recommended to prevent disease, especially in PCOS.
				Prevalence of PCOS in China
				PCOS features in Chinese females
					PCOS and hirsutism
					PCOS phenotypes
					Pooled prevalence rates in China
					Ethnic comparisons
					Trend of prevalence decreasing with age
					PCOS with a history of previous gestational diabetes mellitus, obesity, and lipids
					PCOS and high risk of diabetes
					PCOS and obesity
					PCOS and hyperandrogenism
					Association of PCOS with diabetes and hypertension during pregnancy and preterm delivery
			Taiwan
				Health systems in Taiwan
				Types of healthcare
				Taiwanese health beliefs and their impact on healthcare
				Cultural/religious beliefs prevalent in Taiwan
				PCOS: Prevalence and features in Taiwanese females
					PCOS and depression
					Polycystic ovary morphology
					PCOS and hirsutism
					PCOS with obesity, body mass index, and acne
					Obesity and follicle-stimulating hormone to luteinizing hormone ratios
			Hong Kong
				Healthcare system in Hong Kong
				Use of traditional chinese medicine in Hong Kong
				Prevalence of PCOS in Hong Kong
					PCOS features
					PCOS and metabolic syndrome
					PCOS and risk of diabetes
			Japan
				Healthcare system in Japan
				Religious options for healthcare
				Folk remedies
				Cultural influences
				Health beliefs and their impact on nurse educators
				Ethnicity
				Japanese food culture
				The prevalence of PCOS and associated features in Japanese females
					Prevalence
					PCOS and obesity and hirsutism
					PCOM and type 1 diabetes mellitus
					Liver enzymes and body mass index as risk factors for PCOS
					PCOS and miscarriages
					PCOS and infertility management with metformin
			North Korea
				Healthcare system in North Korea
				Women’s health issues
				Ethnicity
				North Korean food
				PCOS: Prevalence in North Korean females
					PCOS with glucose intolerance, body mass index, and lipid profile in Korean females
			South Korea
				Healthcare in South Korea
				Ethnic groups
				South Korean food culture
				PCOS: Prevalence and features in South Korean females
					Prevalence of PCOS subgroups in South Korean females
					Prevalence of PCOS in youth
					PCOS and inappropriate gonadotropin secretion
					The association of diet with depression in Korean females with PCOS
					Dyslipidemia in Korean females with PCOS
			Macau (Chinese special administrative region)
				Healthcare in Macau
				Women’s health
		Conclusion
		References
	26 Situational analysis of polycystic ovary syndrome in Southeast Asia
		Brunei
			Health systems in Brunei
			Health-seeking behaviors
			Women’s health
		Cambodia
			Health systems in Cambodia
			Maternal health
		East Timor (Timor-Leste)
			Health systems in Timor-Leste
			Women’s health
		Indonesia
			Health systems in Indonesia
			Prevalence of polycystic ovary syndrome in Indonesia
			Polycystic ovary syndrome and factors affecting the incidence of PCOS
			Polycystic ovary syndrome and infertility management
		Laos
			Health systems in Laos
			Women’s health in Laos
		Malaysia
			Healthcare in Malaysia
			Healthcare-seeking behavior in Malaysia (research studies)
			Women’s health
			Prevalence of polycystic ovary syndrome in Malaysia
			Polycystic ovary syndrome and dietary supplements
			Polycystic ovary syndrome and specific phenotypes among Malaysian female university staff
			Prevalence of metabolic syndrome in polycystic ovary syndrome
			Polycystic ovary syndrome and the prevalence of metabolic syndrome and hypertriglyceridemic-waist
			Polycystic ovary syndrome and sexual dysfunction
			Polycystic ovary syndrome and a review of the treatments
		Myanmar
			Healthcare in Myanmar
		Philippines
			Healthcare in the Philippines
			Prevalence of polycystic ovary syndrome in the Philippines
			Polycystic ovary syndrome and hirsutism
		Singapore
			Healthcare in Singapore
			Prevalence of polycystic ovary syndrome in Singapore
			Effect of body mass index on phenotypic features of polycystic ovary syndrome
			Polycystic ovary syndrome and lifestyle management practices
		Thailand
			Healthcare in Thailand
			Other types of healthcare and public health research
			Thai traditional medicine
			Medicinal plants
			Health-seeking behaviors of the community
			Prevalence of polycystic ovary syndrome in Thailand
				Polycystic ovary syndrome and hyperandrogenism
		Vietnam
			Healthcare in Vietnam
			Prevalence of polycystic ovary syndrome in Vietnam
				Polycystic ovary syndrome and phenotype
				Polycystic ovary syndrome: Awareness and compliance
				Polycystic ovary syndrome and infertility management
		Conclusion
		References
	27 Situation analysis of polycystic ovary syndrome in Western Asia
		Countries in the Northern region of Western Asia
			Republic of Armenia
				Health services delivery system
				Women’s health
			Azerbaijan
				Health services delivery system
				Women’s health
			Georgia
				Health services delivery system
				Women’s health
		Countries in the fertile crescent of Western Asia
			Iraq
				Healthcare delivery system
				Women’s health
				PCOS: Prevalence and features in Iraq
					Prevalence in infertile couples
			Iran
				Healthcare delivery system
				Public health initiatives and research culture of Iranian healthcare system
				PCOS: Prevalence and features in Iran
					Prevalence
					PCOS and presenting features
					Biochemical and hormonal disturbances and PCOS
					PCOS and health-related quality of life
					PCOS and quality of life
					Quality of modified PCOS HRQoL questionnaire
					Quality of PCOS HRQoL questionnaire
					PCOS questionnaire-50 (PCOSQ-50)
					PCOS and vitamin D
			Palestine
				Healthcare in Palestine
				Women’s health in Palestine
			Cyprus
				System of healthcare
				Women’s health issues in cyprus
			Republic of Turkey
				Healthcare of Turkey
				Public health initiatives and research culture in Turkey
				PCOS: Prevalence and features
					Phenotypes
					Phenotypes linked to obesity
					Prevalence as per criteria
					Risk for metabolic syndrome
					Prevalence in Central European Turkey
					PCOS and uterine anomalies
			Lebanon
				Healthcare in Lebanon
				Women’s health
			Syria
				Health situation in Syria
				Women’s health
			Israel
				Healthcare in Israel
				Women’s health
			Jordan
				Health situation in Jordan
				Women’s health and PCOS
					PCOS and anxiety disorders
		Countries situated in the Arab Peninsula
			Kingdom of Saudi Arabia
				Healthcare in Saudi Arabia
				Women’s health issues
				Public health initiatives, research institutions, and publications
				PCOS: Prevalence and features in the population of KSA
					Prevalence of PCOS
					PCOS features
					PCOS and obesity
					PCOS and risk of obesity
					PCOS and hirsutism
					PCOS and infertility management
					PCOS link with BMI and LH/FSH ratios
					PCOS and psychosomatic symptoms
					PCOS and glucose metabolism
					Awareness of PCOS
					PCOS and levels of reproductive hormones
			United Arab Emirates
				Healthcare in UAE
				Health concerns regarding the increasing incidence of PCOS
				PCOS: Prevalence and features in UAE
					PCOS and dyslipidemia in UAE
					Prevalence
					Structured health education program for PCOS
					Risk factors for PCOS
					PCOS and associated factors in Sharjah
					Pooled prevalence of PCOS
					Perceptions regarding reproductive health and PCOS
			Bahrain
				Healthcare delivery system
				PCOS: Prevalence and features in the population of Bahrain
					Identifying appropriate endocrine markers
					DENND1A gene variants in Bahraini Arab females
					Ovarian drilling and pregnancy outcomes
					C-reactive protein/albumin ratio as a biomarker
			Sultanate of Oman
				Health service delivery system
				PCOS: Prevalence and features in the sultanate of Oman
					Prevalence
					PCOS and emotional disturbances
					PCOS and risk of oxidative stress
					Prevalence and features in the Buraimi region of Oman
			Qatar
				Health service delivery system
				Public health initiatives and publications
				PCOS: Prevalence and features in Qatar
					Metabolic features of PCOS
					Metabolic comparison: Ethnic Qatari and UK females
					Risk of diabetes with PCOS
			Kuwait
				Health services delivery system
				Public health initiatives and publications
				PCOS: Prevalence and features in Kuwait
					Prevalence
					Infertility and PCOS
					Laparoscopic ovarian drilling and Anti-Müllerian hormone levels
					PCOS and obesity
		References
	28 Situation analysis, cultural beliefs, lifestyle, and the psychological impact of polycystic ovary syndrome in Europe
		Background
		Situation in Europe
		Cultural beliefs and implication of lifestyle in patients with PCOS
		Psychological impact
		References
	29 Global approach to polycystic ovary syndrome in Africa
		Introduction
		Prevalence of polycystic ovary syndrome in Africa
		Clinical picture of polycystic ovary syndrome in Africans
			Psychosocial and cultural aspects of PCOS in Africa
			Health-seeking behaviors for PCOS in Africans
		Treatment modalities for PCOS in Africa
			PCOS challenges in Africa
			Diagnostic challenges of PCOS in Africa
			Management challenges
		Recommendations and conclusions
		References
	30 Polycystic ovary syndrome in North America
		North America
			Definition
		Polycystic ovary syndrome–associated disorders in females in the United States
			Dermatologic disorders
				Hirsutism and acne
				Hair loss
			Ovulatory dysfunction/menstrual irregularity
			Metabolic syndrome
			Insulin resistance and hyperinsulinemia
			Dyslipidemia
			Diabetes mellitus
			Cancer
				Breast cancer
				Ovarian cancer
				Endometrial cancer
			Fertility in polycystic ovary syndrome
			Pregnancy loss in polycystic ovary syndrome
			Venous thromboembolism
			Cardiovascular disease
			Gastrointestinal and liver issues
			Sleep disorder
			Mood disorders
			Depression
			Anxiety
			Eating disorders
		Diagnosis
		Treatment (according to recommendations made by the ASRM)
			Comorbidities and ethnicity
			Polycystic ovary syndrome in adolescence in the United States
				Diagnosis of adolescent PCOS in USA
				Treatment of adolescent polycystic ovary syndrome in the United States
			Polycystic ovary syndrome and obesity in North America
				Obesity in North America
					Pathophysiology of polycystic ovary syndrome in obese females
					Impact of obesity on females
		References
Index
	A
	B
	C
	D
	E
	F
	G
	H
	I
	J
	K
	L
	M
	N
	O
	P
	Q
	R
	S
	T
	U
	V
	W
	X
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