Thyroid hormonal changes among women with polycystic ovarian syndrome in Baghdad – a case-control study [ version 1 ; peer review : awaiting peer

Polycystic ovarian syndrome is a syndrome of ovarian Background: dysfunction along with the cardinal features of hyperandrogenism and polycystic ovary morphology. The prevalence of polycystic ovaries on ultrasound is around quarter of all women but is not associated with the full syndrome. The study aimed to assess the status of thyroid disorders in polycystic ovarian syndrome (PCOS). This prospective hospital-based case-control study involved Methods: most outpatients aged 13–45 years who visited the Obstetrics, Gynecology, and Infertility clinic at Baghdad Teaching Hospital with complaints of hirsutism and/or oligomenorrhea or infertility. This study included 70 patients, including 50 with PCOS (PCOS group) and 20 without (control group). The PCOS group exhibited significantly higher mean thyroid Results: stimulating hormone level (3.9 vs. 3.1 μIU/L), luteinizing hormone level (15.2 vs. 4.7 mIU/mL), and body mass index (28.6 vs. 24.9 kg/m ; all, p<0.001) and a non-significantly higher follicle-stimulating hormone level (9.2 vs. 5.2 mIU/L) than the control group. : Our results demonstrate a higher prevalence of thyroid Conclusion disorder among women with PCOS.


Introduction
Polycystic ovarian syndrome (PCOS) is a condition of ovarian dysfunction characterized by hyperandrogenism and polycystic ovaries.The global prevalence of polycystic ovaries among women is 25% 1 .PCOS is a state of insulin resistance, which is considered to be the main factor contributing to development of the syndrome; diagnosis is based on the presence of two out of three of the following: clinical and/or biochemical androgen excess, anovulation and polycystic ovaries on pelvic ultrasound 2 .The mechanisms behind these include hyperinsulinemia, disruption of the hypothalamic-pituitary-gonadal axis, dysregulation of ovarian steroidogenesis, as well as genetic and environmental factors 2,3 .PCOS mainly affects women in aged 18-35 3,4 .Previous studies have documented ovarian enlargement and cystic transformation in thyroid disorders [5][6][7][8] .Thyroid disorders and PCOS are of widespread in the general population, however, the precise nature of the relationship between the two disorders is not currently know.Although the pathophysiology of thyroid disorder and PCOS are totally different 6 .Whether this is due to some common factors predisposing an individual to both disorders, or due to a pathophysiological connection between the two disorders has yet to be established 5 .Two factors making the picture more interesting, are that both have different etiopathology, and that reportedly thyroid disorders are more common in PCOS subjects [7][8][9] .PCOS begins soon after menarche age as a endocrinologic abnormality, two most common endocrine symptoms are chronic elevation of luteinizing hormone (LH) and insulin resistance 4,7,9 .The genetic cause of high LH is unknown.Interestingly, neither an elevation in LH nor insulin resistance alone is enough to initiate the PCOS 7,9 .High LH and hyperinsulinemia work synergistically, causing ovarian growth, androgen production, and ovarian cyst formation 4,5,9 .The thyroid gland regulates the rate at which the body converts food for energy, functioning as a thermostat to control the body's metabolism and other systems.If it secretes hormones too fast will increase metabolism and lead to hyperthyroidism, the inverse leads to slow metabolism, resulting in weight gain and hypothyroidism 4,5 .However, it is not yet known whether this is because of factors predisposing an individual to both disorders or a pathophysiological connection between the two disorders.

Study design and setting
This hospital-based case-control study was conducted at the Obstetrics, Gynecology, and Infertility clinic at Baghdad Teaching Hospital.The study took place from January to October 2018.We obtained a medical and surgical history, a complete menstrual history, including menarche and family history of PCOS, and history of hirsutism, acne, alopecia, menstrual irregularities, or infertility, also history about last pregnancy and abortion.Any history of headaches or blurred vision, any signs or symptoms of thyroid dysfunction include acne, hirsutism, deepening of the voice, and increase in muscle mass were recorded.Thyroid hormone levels were tested to rule out thyroid disease as an etiology of anovulation, and LH and follicle-stimulating hormone (FSH) also analyzed.

Participants and eligibility criteria
The study included 50 subjects diagnosed with PCOS and 20 control subjects, who consented to participate of individuals attending the hospital for follow up, treatment and further evaluation.In accordance with the Rotterdam criteria 10 , PCOS was defined by the presence of any two of the following conditions

Participant inclusion criteria:
1. Irregular menstruation: no menses in the past 6 months or menstrual cycle prolonged for more than 35 days 2. Increased androgen levels and/or acne and/or alopecia (androgenic pattern) 11 or biochemical hyperandrogenism (testosterone level >2.0 nmol/L) 3. Polycystic ovaries (follicles 2-9 mm in diameter and ≥12 in number or ovarian volume ≥10 cm 3 ) identified by transabdominal pelvic ultrasonography after excluding other diseases such as congenital adrenal hyperplasia and virilizing tumors 12 .

Control inclusion criteria:
1. Healthy.Good physical, mental, or emotional state 2.Not using of any form of medication.
3. Positive past-surgical history (any surgical procedures as thyroidectomy, nephrectomy, hysterectomy etc.).The control haven't any diseases or operations in past history.

Data collection
All patients were assessed by complete history-taking and clinical examination include general, inspection, palpation, auscultation, neurologic, and ophthalmologic examination.For thyroid hormone analysis, 5 mL of venous blood was collected from each patient, at the Obstetrics, Gynecology, and Infertility clinic at Baghdad Teaching Hospital, and when patients attended hospital.This was performed by lab staff by using tourniquets and syringe to collect venous blood.All samples collected from venous blood from arm into tubes.Samples were checked for complete clot formation prior to centrifugation, and for particulate matter prior to analysis.If the assay was performed within 24 hours after collection, the specimen was stored at 2-8°C.If testing was delayed more than 24 hours, the specimen was separated from the clot or red blood cells and stored frozen (-10°C or colder).Specimens were mixed thoroughly after thawing, by gently inverting, and then centrifuged, to ensure consistency in the results.Special care must be taken to prevent contamination.150 μl of specimen was the minimum volume required to perform the assay.The dilution was performed so that the diluted test results read greater than the sensitivity of the assay, and the concentration of hormones were determined by multiplying the concentration of the diluted sample by the dilution factor (conc. x 10 times dilution

Statistical analysis
Data entry and analysis were performed by using SPSS version 23.Numerical data were expressed as mean±standard deviation and categorical data as percentage.The level of significance, set at p≤0.05, was confirmed by the Student t-test.

Ethical considerations
The Medical Ethical Committee of Baghdad University / College of Pharmacy approved this study (code:100123).Written informed consent was taken from participants upon presentation to the hospital to both participate in the study and for the research team to access their medical records.

Results
The average age of participants was 27.7±4.7 years for the PCOS group and for the control group 26.8±4.7 years.All patients lived in urban cities in Baghdad province.The PCOS group exhibited significantly higher mean body mass index (BMI; 28.6 vs. 24.9kg/m 2 ) and LH level (15.2 vs. 4.7 mIU/mL) and a nonsignificantly higher FSH level (9.2 vs. 5.2 mIU/L) than the control group, (P-values <0.001, <0.001, <0.007, <0.001, respectively) (Table 1 and Underlying data 13 ).There was a significant association between (P-value <0.003) increased body weight and PCOS; while 86% of patients in the PCOS group were overweight or obese, the proportion of overweight/obese patients in the control group did not exceed 50% (Table 2, Table 3).The proportion of patients with elevated TSH levels was significantly greater in the PCOS group than in the control group (52% vs. 10%).At the same time, it is was significant to find that one-fourth of patients in the PCOS group (24%) showed decreased T3 levels (compared to 0% in the control group).There was a significant  and direct correlation between age and T4 level, with increase in age being associated with a coefficient of increase of 0.238 in T4 level.This association was significant only in the PCOS group, in which increase in age was associated with a coefficient of increase of 0.294 per year in T4 level (P-value <0.001), (Table 3).Thyroid function parameters (TSH, T3, and T4 levels) were not correlated with BMI or LH or FSH level.Among the 50 patients with PCOS, 20 (40.4%) had subclinical hypothyroidism (SCH) and 30 (59.6%) were euthyroid (P-values <0.003, <0.001), (Table 4).

Discussion
PCOS is the most common disorder among young women and an important cause of infertility in this age group.PCOS and thyroid disorder are two of the most common endocrine disorders in women, and while these conditions are very different.Hypothyroidism, is more common in women with PCOS than in the general population.Thyroid and PCOS are interconnected by both genetic and environmental factors which are believed to be contributing to thyroid disorders in PCOS, and is known to cause PCOS-like ovaries and overall worsening of PCOS and insulin resistance.
The most obvious connection between thyroid diseases and PCOS seem to be an increase in BMI, which is very prevalent in women with PCOS, observed than control group, (BMI for PCOS =28.6±4.0;BMI for control= 24.9±3.0 with P-value=<0.001).
In the present study, 20 (40%) of 50 patients with PCOS showed SCH.In a previous study, Michalakis et al. reported an SCH prevalence of 23% among patients seeking treatment for infertility, while another study reported a prevalence of 17.5% among patients with PCOS 14 .
A few studies have previously analyzed the prevalence of SCH in subjects with PCOS.Subclinical hypothyroidism is observed among women with PCOS, with an estimated prevalence range of 10-25% 9 .Regarding the impact of subclinical hypothyroidism on the clinical, hormonal or metabolism of women with PCOS, a recent meta-analysis has shown that the coexistence of SCH and PCOS leads to mild alterations in serum lipids, but not in hormone levels (TSH, FSH, LH and their ratio) 9 .
The findings of the present study are similar to those of a study by Enzevaei et al. in Iran, where 25.5% of subjects with PCOS were found to have SCH 15 .Similarly, in a study by Sinha et al.   in India, 22.5% subjects with PCOS were reported to have SCH compared to 8.75% in controls and thyroid antibodies have been shown to be present in 27% of patients with PCOS versus 8% in controls 16 , also indicated the presence of elevated-T3, T4, TSH in patients with PCOS 17 .Kachuei et al. have also reported a significantly higher prevalence of anti-thyroglobulin antibodies in subjects with PCOS than in control subjects in an Iranian population 18 .
Examination and radiology investigations alone is not a reliable test to determine PCOS.TSH measures, T4, and T3 may be more applicable in the diagnosis of PCOS.Relying the combinations of all these is sufficient to make an accurate diagnosis and reason why so many people with PCOS and hypothyroid are not misdiagnosed.

Conclusion
We conclude that most patient with PCOS will have some degree of thyroid dysfunction, especially SCH.PCOS is much  The benefits of publishing with F1000Research: Your article is published within days, with no editorial bias You can publish traditional articles, null/negative results, case reports, data notes and more The peer review process is transparent and collaborative Your article is indexed in PubMed after passing peer review Dedicated customer support at every stage For pre-submission enquiries, contact research@f1000.com

Table 3 . Distribution of women according to study group, weight categories and to thyroid hormone parameters.
, polycystic ovaries, TSH, thyroid-stimulating hormone; T3, triiodothyronine hormone; and T4, thyroxine hormon.more than just oligomenorrhea, amenorrhea, or infertility.Doctors must be aware of the risk factors for PCOS and intervene with a preventive approach, which may restore normal menstrual function, ovulation, and fertility.Therefore, physicians should consider screening for thyroid function tests at PCOS diagnosis, even in the absence of symptoms related with thyroid dysfunction. PCO