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* Corresponding author: Habibah Abdul Hamid, Fellowship Reproductive Medicine and Infertility, Department of
Obstetrics and Gynecology, Faculty of Medicine and Health Sciences, University Putra Malaysia, Selangor, Malaysia.
Tel: 6038947 2653; Email: pcos.upm@gmail.com- habib@upm.edu.my
Prevalence of Polycystic Ovary Syndrome among Malaysian
Female University Staff
Sareh Dashti (PhD)1, Latiffah Abdul Latiff (MD)2, Habibah Abdul Hamid (MD)3*, Suriani
Mohamad Saini (MD)4, Azrin Shah Abu Bakar (MSc)1, Nur Amirah Inani Binti Sabri (MSc)1,
Maimunah Ismail (PhD)5, Ali Jafarzadeh Esfehani (MD, MSc)6
1 Department of Community Health, Faculty of Medicine and Health Sciences, University Putra Malaysia, Selangor, Malaysia
2 Professor, Department of Community Health, Faculty of Medicine and Health Sciences, University Putra Malaysia, Selangor,
Malaysia
3 Fellow, Reproductive Medicine and Infertility, Department of Obstetrics and Gynecology, Faculty of Medicine and Health Sciences,
University Putra Malaysia, Selangor, Malaysia
4 Senior Medical Lecturer, Department of Imaging, Faculty of Medicine and Health Sciences, University Putra Malaysia, Selangor,
Malaysia
5 Professor, Department of Professional Development and Continuing Education, Faculty of Educational Studies, University Putra
Malaysia, Selangor, Malaysia
6 Medical doctor, Department of Community Health, Faculty of Medicine and Health Sciences, University Putra Malaysia, Selangor,
Malaysia
A R T I C L E I N F O
A B S T R A C T
Article type:
Original article
Background & aim: Polycystic ovary syndrome (PCOS) is a metabolic disease with
diverse etiologies. The prevalence of PCOS varies among different ethnicities and
across various geographical and social settings. Scarce data exist on the prevalence
of PCOS in Asia, especially in Malaysia. Regarding this, the present study was
conducted to assess the prevalence of PCOS and its subtypes among the Malaysian
University staff.
Methods: This cross-sectional study was performed on females of reproductive
age working at University Putra Malaysia, Selangor, Malaysia. The study
population was selected through simple random sampling technique. The
women with thyroid abnormalities or adrenal hyperplasia were excluded
from the study. The participants were screened based on anthropometric
measurements, medical history, blood pressure, and pelvic examination, as well
as the presence of hirsutism, acne, and alopecia. The participants were also
assessed for total and free testosterone levels and subjected to ultrasonography.
The PCOS diagnosis was based on Rotterdam criteria. The data were analyzed
using Mann-Whitney U test, t-test, Chi-square test, and logistic regression at the
significance level of 0.05.
Results: A total of 675 females with the mean age of 26.01±7.14 years participated
in this study. The prevalence rate of PCOS was obtained as 12.6%. All PCOS
subjects were detected with hyperandrogenism and polycystic ovary, while
anovulation was present in only one participant (1.2%). Odds of PCOS diagnosis
was significantly related to increased body mass index (OR=1.14, 95% CI: 1.05-
1.25), higher waist circumference (OR=1.06, 95% CI: 1.01-1.11), hirsutism
(OR=20.83, 95% CI: 5.35- 81.13), and amenorrhea (OR=0.18, 95% CI: 0.04-0.69).
Conclusion: This study revealed a high prevalence of PCOS and a specific
phenotype of PCOS among the Malaysian employees.
Article History:
Received: 06-Mar-2018
Accepted: 02-May-2018
Key words:
Epidemiology
Malaysia
Polycystic ovary syndrome
Prevalence
Women’s health
Please cite this paper as:
Dashti S, Abdul Latiff L, Abdul Hamid H, Saini SM, Shah Abu Bakar A, Amirah Inani Binti Sabri N, Ismail M,
Jafarzadeh Esfehani A. Prevalence of Polycystic Ovary Syndrome among Malaysian Female University Staff. Journal
of Midwifery and Reproductive Health. 2019; 7(1): 1560-1568. DOI: 10.22038/jmrh.2018.30370.1329
Running Title Golmakani N et al.
J Midwifery Reprod Health. 2019; 7(1):1560-1568 1561
JMRH
Introduction
Polycystic ovary syndrome (PCOS) is
considered a common metabolic dysfunction
that has a heterogeneous endocrine background
in women of reproductive age (1). The features
of PCOS include hyperandrogenism, hyperin-
sulinemia, luteinizing hormone hypersecretion,
menstrual dysfunction, hirsutism, infertility, and
pregnancy and neonatal complications (1-3).
The PCOS also contributes to long-term
metabolic and physiological complications,
including type II diabetes mellitus, cardiovascular
disease (CVD), and venous thromboembolism.
Moreover, this syndrome may result in poor
self-esteem and anxiety, which require medical
and social support (4-12). Different prevalence
rates have been presented for PCOS in various
countries. Most of the prevalence rates have
been estimated based on small populations (13,
14). The prevalence of PCOS has been reported
to range from 5% to 10% in the majority of the
studies (5, 13-15).
The Rotterdam and National Institute of
Health criteria for PCOS are among the most
common diagnostic tools for this syndrome
(16, 17). The diagnostic criteria in these tools
include the detection of toligoovulation or
anovulation, hyperandrogenism (based on
clinical or biochemical findings), and polycystic
ovaries (based on ultrasound scan). The PCOS
might have various clinical manifestations due
to its diverse symptoms.
Based on the Rotterdam criteria, PCOS
features can be divided into four categories: 1)
the first phenotype is defined as the presence
of a combination of hyperandrogenism (H) and
chronic anovulation (O) in the presence of
normal ovaries (H+O), 2) the second phenotype
includes hyperandrogenism and polycystic
ovaries with ovulatory cycles (H+P), 3) the
third phenotype entails a combination of
chronic anovulation and polycystic ovaries
without clinical or biochemical indicators for
hyperandrogenism (O+P), and 4) the fourth
phenotype includes the simultaneous presence
of hyperandrogenism, chronic anovulation, and
polycystic ovaries (H+O+P) (16).
Phenotypic variability of PCOS could be due
to various factors, including difficult diagnosis,
need for blood or ultrasound assessments, and
variability of diagnostic criteria (e.g., NIH
criteria or the Rotterdam ESHRE/ASRM-
Sponsored PCOS Consensus Workshop Group
criteria). There is a paucity of large-scale studies
investigating the prevalence of PCOS even in
developed countries (5, 18). Furthermore, with
regard to the rapid changes in lifestyles in
developing countries like China, there is concern
that PCOS may become epidemic (19).
The prevalence of PCOS is not well defined in
Southeast Asian countries, including Malaysia.
Given the health risks of PCOS, it seems both
important and necessary to evaluate the current
status and features of PCOS in the community
and identifies the risk factors for this syndrome
to design and implement interventions in order
to prevent from this disorder and manage the
affected women in the community. With this
background in mind, the present study aimed to
assess the prevalence of PCOS and its risk
factors among the university staff working at a
large governmental university of Malaysia.
Materials and Methods
Study design and research population
This cross-sectional study was conducted on
females at the risk of PCOS working at 16
faculties of University Putra Malaysia, Selangor,
Malaysia. The study population was selected
through random sampling technique based on a
list obtained from the University Human
Resource section. Announcements were provided
prior to visiting each faculty, and the female staff
were informed about the venue and objectives of
the research. In order to reduce the dropout rate
and subject refusal, researchers referred to each
university faculty at the due date to obtain
measurements and perform sampling. The
women of childbearing age (i.e., 18-49 years) and
those willing to participate were included in the
study. On the other hand, the exclusion criteria
were: 1) consumption of oral contraceptives for
more than 4 weeks, 2) use of hormonal treatment
or insulin-sensitizing agents for more than 2
weeks, 3) abnormal thyroid findings, 4)
nonclassical adrenal hyperplasia, 5) diagnosis
with such conditions as hyperprolactinemia,
hypogonadotropic hypogonadism, premature
ovarian failure, ovarian cysts or tumors,
congenital adrenal hyperplasia, androgen-
secreting tumor, Cushing’s syndrome, uterine
Dashti S et al. Prevalence of Polycystic Ovarian Syndrome in Malaysian Women
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disorders, and chromosomal anomalies, 6)
pregnancy, and 7) menopause.
Screening protocol and assessment criteria
The data were collected using a questionnaire,
including items regarding personal information,
menstruation and obstetric history, dermal
features of hyperandrogenism, and endocrine
and metabolic diseases. The participants were
subjected to out of charge physical, pelvic, and
ultrasound examinations.
Research instrument
The questionnaire covered patients’ infor-
mation, including age, age of menarche,
menstruation history, family history,
hyperandrogenism-related skin problems (e.g.,
hirsutism, acne, and premature alopecia),
metabolic diseases, and other gynecologic
diseases. Oligomenorrhea was defined based on
such criteria as fewer than eight menstrual
cycles per year or elongated menstrual cycle
duration for more than 35 days. Furthermore,
amenorrhea was considered as the lack of
menstruation for 3-6 consecutive menstrual
cycles, or 4 ≥ menstrual periods per year (20).
The questionnaire was developed by the
researchers based on literature review. The face
and content validities of the questionnaire were
assessed by a panel of experts in reproductive
medicine and epidemiologists prior to the study.
Three interviewers (i.e., one postgraduate
student studying at the university under
investigation and two research assistants) were
fully instructed to use the standardized
questionnaire and perform the required physical
examinations.
Physical examination
Physical examination included the measure-
ment of blood pressure, calculation of body mass
index (BMI) based on weight and height
measurements, and examination of breast and
thyroid gland. Hirsutism was assessed based on
the modified Ferriman-Gallwey (mF-G) score.
Other features of hyperandrogenism, including
acne and premature alopecia, were also assessed
during the physical examination. Additionally,
physical and pelvic examinations were
performed for each participant to determine the
presence of any uterine or ovarian disorders.
The mF-G scoring system classifies the
severity of hirsutism by providing a scoring
system for the presence of terminal hair in nine
body areas (21, 22). The final score is obtained
by summing up the score of each area (maximum
score: 36). Each area is rated on a five-point
Likert scale ranging from 0 (i.e., absence of
terminal hair) to 4 (i.e., extensive terminal hair
growth). Terminal hair was distinguished from
villus hair based on the length (longer than 0.5
cm) and pigmentation. An mF-G score of ≥ 6 is
considered as hirsutism (23).
The grading of acne was performed based on
the evaluation of the acne features, including
papules, pustules, and nodules, as well as its
distribution in various regions, including the
cheeks, neck, chest, and upper back. The
Consensus Conference on Acne Classification
grading was used for grading the severity of
acne in the study participant (24).
Ultrasound examination
Each participant underwent an ultrasound
scan during the clinical examination to
determine the number of follicles and ovarian
volume. Diagnosis of PCOS was based on the
observation of 12 or more follicles with a
diameter range of 2-9 mm in each ovary and/or
enhancement of each ovary volume by at least
10 ml (16).
Metabolic and other assessments
Metabolic syndrome was identified based on
the modified National Cholesterol Education
Program adult treatment panel III guidelines in
2005 (25).
Diagnosis of polycystic ovary syndrome
The Rotterdam criteria were used to diagnose
PCOS. The diagnosis of this syndrome was
confirmed by the presence of at least two of the
three criteria, namely oligo/amenorrhea, clinical
and/or biochemical hyperandrogenism, and
polycystic ovaries. Oligo/amenorrhea is defined
as the lack of menstruation for at least 35 days or
3-6 consecutive menstrual cycles, or ≤ 4
menstrual periods per year. Hyperandrogenism
was identified based on the clinical and
biochemical indicators of hyperandrogenism,
including mF-G score of ≥ 6 with or without acne,
and/or androgenic alopecia. Furthermore,
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laboratory measurements were performed to
assess hyperandrogenism including serum
androstenedione of 10.8 nmol/l or total
testosterone of 2.81 nmol/l. Anovulation was
assessed by measuring serum luteal
progesterone in subjects with a history of
oligo/amenorrhea. A minimum progesterone
level of 10 nmol/l was considered as
oligoovulation.
Hormonal assays
Participants with a confirmed diagnosis of
PCOS based on the Rotterdam criteria were
subjected to clinical examinations, ultrasound
examinations, and hormone tests. All blood
samples were collected in the morning after
fasting for at least 8 h. Total and free testosterone
levels were assessed by chemiluminescence
using the Immulite 1000 (DPC, USA). For all
measurements, the inter- and intra-assay
coefficients of variation were < 10% and <
15%, respectively. In addition, fasting glucose,
cholesterol, triglyceride, low- and high-density
lipoprotein, thyroid stimulating hormone, and T4
were measured in all participants.
Statistical analysis
Statistical analysis was performed in SPSS
software for Windows, version 21 (SPSS, Inc.,
Chicago, IL, USA). Descriptive statistics were
used to assess data distribution to compare
variables between groups. Continuous variables
were checked for normality using Shapiro-Wilk
test. The data were presented as mean, standard
deviation, median, and interquartile range
(IQR). The comparison of the continuous
variables was compared using Student’s t-test or
Mann-Whitney U test.
In addition, the categorical variables were
presented as frequency and percentage and
compared using Pearson’s Chi-square test.
Univariate logistic regression was used
to examine the independent predictors.
Multivariate logistic regression was also utilized
to adjust for other variables using PCOS
diagnosis as a dependent variable and other
variables as independent variables. The weight
and body fat percentage were excluded from the
model due to the association between these
variables; however, the BMI was remained in the
model. P-value less than 0.05 was considered
statistically significant. The odds ratios (ORs)
was modeled to analyze the risk factors for PCOS.
Results
Based on the list obtained from the Human
Recourse office of the UPM, 1,424 females were
working at this university. Out of 1,424 female
university staff, 26 cases were excluded due to
lacking the eligibility criteria; therefore, 675
(47.4%) subjects participated in the study. The
main reasons for refusal to participate in the
study were lack of time, schedule mismatch
between sampling time and university
programs, sick leave, and fear of blood
withdrawal.
Table 1 presents the demographic
characteristics of the participants. Out of 675
participants, 85 (12.6%) cases were diagnosed
with PCOS according to the Rotterdam criteria.
A total of 85 PCOS women responded to
the questionnaire and underwent physical
examination, ultrasound, and blood tests. All
participants had elevated levels of total and free
testosterone. In this regard, the median and IQR
of total testosterone were both 0.9, and the
Table 1. Characteristics of patients with polycystic ovary syndrome and normal participants
Total
n=675
Normal
n=590
PCOS
n=85
P-value
Age (years)†
26.01±7.14
25.11±6.76
32.43±6.44
<0.001**
Weight (kg)†
59.57±14.63
57.57±12.79
73.84±18.60
<0.001**
Height (cm)†
156.12±6.43
156.29±5.46
154.89±11.11
0.06
BMI (kg/m2)†
24.47±6.09
23.55±5.02
31.03±8.58
<0.001**
Waist circumference (cm)†
77.57±11.33
75.97±10.12
88.93±12.96
<0.001**
Body fat (%)†
31.99±6.92
31.10±6.62
38.41±5.51
<0.001**
SBP (mmHg)†
114.80±12.25
113.90±11.24
121.15±16.64
<0.001**
DBP (mmHg)†
70.23±9.47
69.58±9.14
74.85±10.48
<0.001**
Acne‡
274 (40.6%)
256 (43.2%)
18 (21.7%)
<0.001**
Hirsutism‡
52 (7.7%)
30 (5.1%)
22 (26.5%)
<0.001**
Amenorrhea§
3 (0.4%)
2 (0.3%)
1 (1.2%)
0.33
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1564 J Midwifery Reprod Health. 2019; 7(1):1560-1568.
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PCOS: polycystic ovary syndrome, BMI: body mass index, SBP: systolic blood pressure, DBP: diastolic blood pressure
† Data were shown as mean and SD, and independent t-test was used for comparison.
‡ Data were shown as frequency and percentage, and Chi-square test was used for comparison. Percentages
represent the number of participants divided by the adjacent group population multiplied by 100.
§ Data were shown as frequency and percentage, and Fisher’s exact test was used for comparison. Percentages
represent the number of participants divided by the adjacent group population multiplied by 100.
** Significant at α=0.01
Table 2. Relationship between polycystic ovary syndrome diagnosis and study variables
Variable
P-value
OR
95% CI
Adjusted
regression
P-value
Adjusted
OR
95% CI
Lower
Upper
Lower
Upper
Age (years)
<0.001**
1.08
1.04
1.12
0.76
1.01
0.93
1.01
Weight (kg)
0.23
0.96
0.91
1.02
-
-
-
-
BMI (kg/m2)
0.04*
1.16
1.00
1.35
0.003**
1.14
1.05
1.25
Waist circumference (cm)
0.71
1.01
0.97
1.05
0.02*
1.06
1.01
1.11
Body fat (%)
0.10
1.07
0.99
1.16
-
-
-
-
SBP (mmHg)
0.63
0.99
0.96
1.02
0.79
1.01
0.95
1.07
DBP (mmHg)
0.26
1.03
0.98
1.07
0.06
1.07
0.99
1.14
Acne
0.13
0.63
0.34
1.16
0.76
1.12
0.34
4.36
Hirsutism
<0.001**
4.82
2.37
9.80
<0.001**
20.83
5.35
81.13
Amenorrhea
0.63
0.54
0.04
6.53
0.01*
0.18
0.04
0.69
BMI: body mass index, SBP: systolic blood pressure, DBP: diastolic blood pressure
* Significant at α=0.05
** Significant at α=0.01
mean level of free testosterone was 12.38±2.90.
Furthermore, they had positive ultrasound
findings for polycystic ovary. Anovulation was
present in only 1 (1.2%) participant (H+P+O
subtype), while the rest of the participants
(98.8%) were in the H+P subtype. No other
subtypes of PCOS were observed in the study
population.
Based on the findings of the univariate
logistic regression, the participants with PCOS
diagnosis had significantly higher age (OR=1.08,
95% CI: 1.04-1.12, P<0.001), BMI (OR=1.16,
95% CI: 1.00-1.35), and hirsutism prevalence
(OR=4.82, 95% CI: 2.37-9.80), compared with
the normal participants (Table 2). Table 2
summarizes the results of multivariate
regression analysis. The odds of PCOS diagnosis
was significantly related to increased BMI
(OR=1.14, 95% CI: 1.05-1.25), higher waist
circumference (OR=1.06, 95% CI: 1.01-1.11),
hirsutism (OR=20.83, 95% CI: 5.35-81.13), and
amenorrhea (OR=0.18, 95% CI: 0.04-0.69).
Discussion
The prevalence of PCOS reportedly ranges
from 2.4% to 52% (2, 26-29). According to the
literature, the prevalence of this syndrome is
affected by the applied diagnostic criteria and
geographical diversity given the role of the
genetic and environmental factors in this
disorder (2, 26, 27). There is a paucity of data
regarding the prevalence of PCOS in the South
Asian regions. Moreover, the existing data are
inconsistent mainly due to the differences in the
chosen diagnostic criteria (30).
The prevalence rate of PCOS in the Asian
regions has a range of 2.4-9% in China, Seri
Lanka, and India (27, 28, 31, 32). In this study,
the prevalence of PCOS among the Malaysian
university staff was obtained as 12.6%, which is
close to the rates previously reported for the
Asian population. In the previous studies, the
prevalence of PCOS was reported to be higher
in the Asian population from the Indian
subcontinent origin, compared with that in the
White Asians. In addition, the highest prevalence
of PCOS among the Indian population was
observed in the immigrant Indians in the United
Kingdom (52%) in 1988 (29, 33).
In contrast, the observed prevalence of PCOS
in this study was higher than the prevalence
rates reported for the Chinese community-
dwelling women (5.6% and 2.4%) and Indian
adolescents (9%). The reason for this difference
might be due to the variations in study
participants. While the aforementioned studies
were mainly conducted on community-dwelling
adults or adolescents, the current study was
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performed on female employees, who are
known for their sedentary lifestyle.
Moreover, the criteria for PCOS diagnosis
varied among this research and some of the
previous studies. Previous studies mainly used
Rotterdam criteria for the diagnosis of PCOS;
therefore, they could be more easily compared
with one another (27, 28, 31). The findings of
this study indicated the possibility of higher
prevalence of PCOS among the Malaysian
population, compared to those in the other
Asian countries.
This study revealed that the participants
diagnosed with PCOS were significantly older
than the normal subjects. It was previously
shown that PCOS prevalence reduces with an
increase in age from 30 to 34 years, compared
with that in individuals aged above 35 years
(34). The difference between the observed trend
of PCOS diagnosis among older age in the
current study might be due to the narrow age
range of the participants in this study as most
of the participants aged below 35 years.
Furthermore, statistical analysis was not
applicable to higher age groups due to the small
number of the participants older than 35 years.
On the other hand, the multivariate analysis
revealed no significant relationship between age
and PCOS diagnosis, which can also indicate that
the age of the subjects was distributed evenly in
the study population. Therefore, the higher
incidence of PCOS in other age groups was not
assessed in the analysis.
The significant association between hirsutism
and PCOS diagnosis in this study can be due to
the elevated levels of total and free testosterone.
Moreover, polycystic ovaries were also positive
in all 85 PCOS cases (H+P type). It was
previously hypothesized that hyperandrogenism
is more prominent in PCOS women of the Asian
origin, compared to that in Caucasians (35). This
finding can be the reason for the observation of a
hyperandrogenism prevalence rate of 100%
among PCOS cases in the current study.
In a study investigating ovarian morphology
in PCOS women in Japan, the presence of
polycystic ovaries was associated with
hyperandrogenism (36). On the other hand,
polycystic ovaries have been found to be
associated with increased insulin resistance,
diabetes mellitus, and obesity (37). Our findings
are in line with those of the mentioned studies
as the odds of PCOS diagnosis was higher in the
participants with higher BMIs (2, 26, 38).
In another study examining the pattern of
PCOS subtypes in white and South Asian
ethnicities, the odds of PCOS diagnosis was
increased with the enhancement of hirsutism
prevalence in South Asians, compared with that
in the white Asians (39, 40). The findings of this
study can also strengthen the hypothesis that a
certain PCOS phenotype may exist in the Asian
ethnicities (39, 40). This proposed Asian
phenotype is also associated with increased
prevalence of type II diabetes mellitus, as well
as increased systolic and diastolic blood
pressure, which were also observed in the
current study (39, 40). The reason for the
achievement of a high OR in this study might be
due to the small number of subjects with
hirsutism (7.7%).
Our results revealed that amenorrhea was
associated with the reduced risk of PCOS. This
finding was in contrast with the definition of
PCOS, which includes oligo/amenorrhea (26,
41). This discrepancy might be due to the small
number of subjects with amenorrhea and the
existence of a different phenotype of PCOS
among the subjects. Therefore, further studies
should be conducted to identify the PCOS
phenotype and association between PCOS
diagnostic criteria among Malaysian women.
The significant association between
abdominal obesity (i.e., increased BMI and waist
circumference) and increased odds of PCOS
diagnosis may be also related to the higher
prevalence of metabolic syndrome among PCOS
women, compared to that in normal population.
It was also shown that the prevalence of
metabolic syndrome was higher among Asians
with PCOS, compared with that in Caucasians
(40). Although the prevalence of metabolic
syndrome could not be assessed in all study
participants due to the financial limitations and
restraints in blood sampling, metabolic
syndrome could be an underlying cause of
insulin resistance and PCOS.
This was the first large-scale study that
assessed the prevalence of PCOS among women
of reproductive age working at the largest public
university in Malaysia. The high prevalence of
PCOS (12.6%) among Malaysian women could
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be a sign of an emerging public health issue in
Malaysia. Regarding this, more studies are
required on larger scales to identify the burden
of PCOS in Malaysian population. The findings of
this study also suggested the necessity for
adopting preventive strategies through health
education, as well as the prevention and
treatment of PCOS in community-dwelling
women, especially those who are obese. Further
research should examine the prevalence of
metabolic syndrome and each of its criteria
among Malaysian women with PCOS in order to
shed light on the focus of attention in the
treatment of women with PCOS in Malaysia.
The strengths of this study are the
assessment of the prevalence of PCOS and its
subtypes in community-dwelling Malaysian
women by using nationally approved diagnostic
criteria. This study also evaluated some of the
PCOS-associated risk factors for CVD, including
BMI, serum lipids, and blood pressure. The most
important limitation of this study was the non-
implementation of blood sampling for all
participants due to financial limitations.
Therefore, a number of CVD risk factors and
metabolic syndrome criteria could not be
assessed in this study. It is recommended to
perform further research to assess CVD serum
markers in PCOS women.
Conclusion
The findings of the present study revealed a
high prevalence of PCOS among Malaysian
employees that may require urgent health
education interventions in order to prevent the
associated consequences. This study also
strengthened the hypothesis regarding the
presence of a specific phenotype of PCOS among
Asian population.
Acknowledgements
This original article will form a part of a PhD
thesis that would be submitted by Sareh Dashti
and supervised by Dr. Latiffah A. Latiff, Dr.
Habibah A. Hamid, and Dr. Maimunah Ismail.
The current study was approved by the Ethical
Committee of University Putra Malaysia
(UPM/TNCPI/RMC/1.4.18.1(JKEUPM)/F2). This
project was financially supported by a grant
from the Ministry of Science, Technology, and
Innovation (grant numbers 06-01-04SF1847,
2013).
Conflicts of interest
The authors declare no conflicts of interest.
References
1. Qiao J, Feng HL. Extra-and intra-ovarian factors
in polycystic ovary syndrome: impact on
oocyte maturation and embryo developmental
competence. Human Reproduction Update. 2011;
17(1):17-33.
2. Dumesic DA, Oberfield SE, Stener-Victorin E,
Marshall JC, Laven JS, Legro RS. Scientific statement
on the diagnostic criteria, epidemiology,
pathophysiology, and molecular genetics of
polycystic ovary syndrome. Endocrine Reviews.
2015; 36(5):487-525.
3. Walters KA. Androgens in polycystic ovary
syndrome: lessons from experimental models.
Current Opinion in Endocrinology, Diabetes, and
Obesity. 2016; 23(3):257-263.
4. Hart P, Eaton L, Buckner M, Morrow BN, Barrett
DT, Fraser DD, et al. Effectiveness of a computer-
based educational program on nurses’ knowledge,
attitude, and skill level related to evidence-based
practice. Worldviews on Evidence-Based Nursing.
2008; 5(2):75-84.
5. Apridonidze T, Essah PA, Iuorno MJ, Nestler JE.
Prevalence and characteristics of the metabolic
syndrome in women with polycystic ovary
syndrome. Journal of Clinical Endocrinology and
Metabolism. 2005; 90(4):1929-1935.
6. Meyer C, McGrath BP, Teede HJ. Overweight
women with polycystic ovary syndrome have
evidence of subclinical cardiovascular disease.
Journal of Clinical Endocrinology Metabolism.
2005; 90(10):5711-5716.
7. Boomsma CM, Eijkemans MJ, Hughes EG, Visser
GH, Fauser BC, Macklon NS. A meta-analysis of
pregnancy outcomes in women with polycystic
ovary syndrome. Human Reproduction Update.
2006; 12(6):673-683.
8. Jones GL, Hall JM, Balen AH, Ledger WL. Health-
related quality of life measurement in women
with polycystic ovary syndrome: a systematic
review. Human Reproduction Update. 2008;
14(1):15-25.
9. Okoroh EM, Hooper WC, Atrash HK, Yusuf HR,
Boulet SL. Is polycystic ovary syndrome another
risk factor for venous thromboembolism? United
States, 2003-2008. American Journal of Obstetrics
and Gynecology. 2012; 207(5):377-e1-8.
10. Bird ST, Hartzema AG, Brophy JM, Etminan M,
Delaney JA. Risk of venous thromboembolism in
women with polycystic ovary syndrome: a
population-based matched cohort analysis.
Canadian Medical Association Journal. 2013;
Prevalence of Polycystic Ovarian Syndrome in Malaysian Women Dashti S et al.
J Midwifery Reprod Health. 2019; 7(1):1560-1568. 1567
JMRH
185(2):E115-E120.
11. Dashti S, Latiff LA, Hamid HA, Sani SM, Akhtari-
Zavare M, Abu Bakar AS, et al. Sexual dysfunction
in patients with polycystic ovary syndrome in
malaysia. Asian Pacific Journal of Cancer
Prevention. 2016; 17(8):3747-3751.
12. Dashti S, Latiff LA, Zulkefli NA, Baharom AB,
Minhat HS, Hamid HA, et al. A review on the
assessment of the efficacy of common treatments
in polycystic ovarian syndrome on prevention of
diabetes mellitus. Journal of Family and
Reproductive Health. 2017; 11(2):56-66.
13. Asunción M, Calvo RM, San Millán JL, Sancho J,
Avila S, Escobar-Morreale HF. A prospective study
of the prevalence of the polycystic ovary
syndrome in unselected caucasian women
from Spain. Journal of Clinical Endocrinology
Metabolism. 2000; 85(7):2434-2438.
14. March WA, Moore VM, Willson KJ, Phillips DI,
Norman RJ, Davies MJ. The prevalence of polycystic
ovary syndrome in a community sample assessed
under contrasting diagnostic criteria. Human
Reproduction. 2010; 25(2):544-551.
15. Franks S. Polycystic ovary syndrome. New England
Journal of Medicine. 1995; 333(13):853-861.
16. Rotterdam ESHRE/ASRM-Sponsored PCOS
Consensus Workshop Group. Revised 2003
consensus on diagnostic criteria and long-term
health risks related to polycystic ovary syndrome.
Fertility and Sterility. 2004; 81(1):19-25.
17. Johnson T, Kaplan L, Ouyang P, Rizza R. National
Institutes of Health evidence-based methodology
workshop on polycystic ovary syndrome (PCOS).
NIH EbMW Report. Bethesda National Institute of
Health. 2012; 1:1-14.
18. Carmina E, Napoli N, Longo RA, Rini GB, Lobo RA.
Metabolic syndrome in polycystic ovary syndrome
(PCOS): lower prevalence in southern Italy than in
the USA and the influence of criteria for the
diagnosis of PCOS. European Journal of
Endocrinology. 2006; 154(1):141-145.
19. Wang L. China national nutrition and health
survey 2002. Beijing: People’s Medical Publishing
House; 2005.
20. Rumball JS, Lebrun CM. Use of the
preparticipation physical examination form to
screen for the female athlete triad in Canadian
interuniversity sport universities. Clinical Journal
of Sport Medicine. 2005; 15(5):320-325.
21. Ferriman D, Gallwey JD. Clinical assessment of
body hair growth in women. Journal of Clinical
Endocrinology and Metabolism. 1961; 21(11):
1440-1447.
22. Hatch R, Rosenfield RL, Kim MH, Tredway D.
Hirsutism: implications, etiology, and management.
American Journal of Obstetrics Gynecology. 1981;
140(7):815-830.
23. Ichikawa Y, Asai M, Masahashi T, Wu MC, Ohsawa
M, Narita O, et al. Clinical assessment of body hair
growth in Japanese women. The relationship
between a grade of hirsutism and the menstrual
status. Nihon Sanka Fujinka Gakkai Zasshi. 1988;
40(11):1719-1724.
24. Reingold SB, Rosenfield RL. The relationship of
mild hirsutism or acne in women to androgens.
Archives of Dermatology. 1987; 123(2):209-212.
25. Alberti KG, Zimmet P, Shaw J, IDF Epidemiology
Task Force Consensus Group. The metabolic
syndrome--a new worldwide definition. Lancet.
2005; 366(9491):1059-1062.
26. Sirmans SM, Pate KA. Epidemiology, diagnosis,
and management of polycystic ovary syndrome.
Clinical Epidemiology. 2013; 6:1-13.
27. Li R, Zhang Q, Yang D, Li S, Lu S, Wu X, et al.
Prevalence of polycystic ovary syndrome in
women in China: a large community-based study.
Human Reproduction. 2013; 28(9):2562-2569.
28. Kumarapeli V, Seneviratne Rde A, Wijeyaratne CN,
Yapa RM, Dodampahala SH. A simple screening
approach for assessing community prevalence
and phenotype of polycystic ovary syndrome in a
semi-urban population in Sri Lanka. American
Journal of Epidemiology. 2008; 168(3):321-328.
29. Rodin DA, Bano G, Bland JM, Taylor K, Nussey SS.
Polycystic ovaries and associated metabolic
abnormalities in Indian subcontinent Asian women.
Clinical Endocrinology. 1998; 49(1):91-99.
30. Wijeyaratne CN, Balen AH, Belchetz PE. Polycystic
ovary syndrome and its relevance to women
from south Asia. Ceylon Medical Journal. 2002;
47(1):22-26.
31. Nidhi R, Padmalatha V, Nagarathna R, Amritanshu
R. Prevalence of polycystic ovarian syndrome in
Indian adolescents. Journal of Pediatric and
Adolescent Gynecology. 2011; 24(4):223-227.
32. Chen X, Yang D, Mo Y, Li L, Chen Y, Huang Y.
Prevalence of polycystic ovary syndrome in
unselected women from southern China.
European Journal of Obstetrics, Gynecology, and
Reproductive Biology. 2008; 139(1):59-64.
33. Wang S, Alvero R. Racial and ethnic differences in
physiology and clinical symptoms of polycystic
ovary syndrome. Seminars in Reproductive
Medicine. 2013; 31(5):365-369.
34. Lauritsen MP, Bentzen JG, Pinborg A, Loft A,
Forman JL, Thuesen LL, et al. The prevalence of
polycystic ovary syndrome in a normal population
according to the Rotterdam criteria versus revised
criteria including anti-Müllerian hormone. Human
Reproduction. 2014; 29(4):791-801.
35. Huang Z, Yong EL. Ethnic differences: is there
an Asian phenotype for polycystic ovarian
syndrome? Best practice & research. Clinical
Obstetrics & Gynaecology. 2016; 37:46-55.
Dashti S et al. Prevalence of Polycystic Ovarian Syndrome in Malaysian Women
1568 J Midwifery Reprod Health. 2019; 7(1):1560-1568.
JMRH
36. Miyoshi A, Nagai S, Takeda M, Kondo T, Nomoto
H, Kameda H, et al. Ovarian morphology and
prevalence of polycystic ovary syndrome in
Japanese women with type 1 diabetes mellitus.
Journal of Diabetes Investigation. 2013; 4(3):
326-329.
37. Palomba S, Falbo A, Zullo F, Orio F Jr. Evidence-
based and potential benefits of metformin in the
polycystic ovary syndrome: a comprehensive
review. Endocrine Reviews. 2009; 30(1):1-50.
38. Jones GL, Palep-Singh M, Ledger WL, Balen AH,
Jenkinson C, Campbell MJ, et al. Do South Asian
women with PCOS have poorer health-related
quality of life than Caucasian women with PCOS?
A comparative cross-sectional study. Health and
Quality of Life Outcomes. 2010; 8:149.
39. Mani H, Davies MJ, Bodicoat DH, Levy MJ, Gray
LJ, Howlett TA, et al. Clinical characteristics
of polycystic ovary syndrome: investigating
differences in white and south Asian women.
Clinical Endocrinology. 2015; 83(4):542-549.
40. Mehta J, Kamdar V, Dumesic D. Phenotypic
expression of polycystic ovary syndrome in south
Asian women. Obstetrical and Gynecological
Survey. 2013; 68(3):228-234.
41. Conway G, Dewailly D, Diamanti-Kandarakis E,
Escobar-Morreale HF, Franks S, Gambineri A, et al.
The polycystic ovary syndrome: a position
statement from the European Society of
Endocrinology. European Journal of Endocrinology.
2014; 171(4):P1-P29.
