Polycystic ovary syndrome (PCOS), the most common endocrinopathy affecting women's health, is characterized by ovarian dysfunction and hormonal variation, which typically begins in adolescence (Hashmi et al., 2024). Additionally, 90–95% of women in infertility clinics have it as their primary cause of infertility (Shrivastava & Conigliaro, 2023). PCOS and insulin resistance have a significant association hypothesize multisystem links in the pathogenesis of this disease (Nisa et al., 2024). In between 50% and 70% of women with PCOS, there is insulin resistance and hyperinsulinemia. (Cherian & Paul, 2024). Proper treatment during the 20-40 age range or earlier in a woman's life can impact her ability to get pregnant. Providers play a role in determining treatment plans for these women. Providers should make appropriate recommendations for these women based on available evidence, so most women followed clinical recommendations (Moss et al., 2024). Weight loss is one of the primary therapies for PCOS. Metformin is a drug often used in the case of PCOS, which contributes to lowering the level of insulin and androgens, thus restoring the regularity of ovulatory periods. Additionally, it not only improves the lipid profile and antioxidant characteristics and increases the levels of sex hormone binding globulin (SHBG) (Nassif et al., 2024). The etiology and pathophysiology of PCOS are not fully known. The etiology of this complex disorder remains somewhat doubtful.

Certain environmental factors and genetic predisposition have been observed as disease-driving elements (Lentscher et al., 2021). Environmental factors such as poor nutrition and insufficient exercise may contribute to the aetiology and progression of PCOS (Nautiyal et al., 2022). Observed contributing risk factors for PCOS include age, BMI, menstrual irregularity, and family history of PCOS (Sachdeva et al., 2019).

Sample collection 

The current study was conducted in Nineveh Governorate, included (120) blood samples as a total of (60) blood samples were taken from PCOS patients and (60) blood samples were taken from the healthy control group. The study group included different age groups ranging from(18-45) years. 

Data collection 

The information data collected as questionnaires as listed in table (1),described the data collection method used in the present study. The information form was designed and used to collect data for patients hospitalized in Mosul city hospitals (Al-Khansa Teaching Hospital and Al-Salam Teaching Hospital) for the period  between 10 November 2023 to 20 February 2024.   

Table(1): Information Form Of PCOS Patients

Physiological Study Of PCOS

According to the clinical or physiological features of the PCOS women, the results of our study may similar or differ with local and international previous studies can be ascribed to several reasons, including the difference in the size of the clinical sample collection, physiological and immunological response of population groups, microbiologic techniques, in addition to the application of primary health care programs. 

Table (2) below shows no significant difference (P-value >0.05) in age between PCOS and control groups, with mean values of (29.11±7.14) and (31.10±6.89), respectively. PCOS patients had a BMI of (27.33±3.63 Kg/m²), while the control group had a BMI of (26.62±4.19). This difference between the groups under study was not statistically significant.

The current findings were consistent with (Abdalqader et al., 2020), who concluded that there were no significant differences in age between PCOS patients and the control group, as well as (Moosa et al., 2020 and Torcia et al., 2019).

 The absence of a significant difference between groups indicates neutrality in the results because age is related to immunity, hormone factors, hormone secretion, and other factors. The similarities between these studies regarding the same age group because PCOS appeared at menarche and the women became symptomatic later but most women with PCOS are diagnosed between the ages of 20 and 30 (Bronstein et al., 2011). 

Regarding BMI, the current results agreed with (Ibraheem et al., 2022) who reported a non-significant difference in BMI between the PCOS group and the control group. According to the current research, Iraqi women with PCOS have a higher upper body weight than women with the disease in other countries (Ibraheem et al., 2022) and (sarhat et al.,2021), which may be related to the different food habits in our country and the low level of physical activity among Iraqi women.

A healthier lifestyle can help PCOS patients who gain weight because studies have shown that this lowers testosterone levels, which raise insulin sensitivity, and improves hormonal health. (Cena et al., 20190).

Additionally, the mean and standard deviation of Estradiol (E2) was (193.27±38.46) in the control group and (108.66±29.41) in PCOS cases. Significant differences (P-value <0.05) were found between the PCOS patients and the control group. The present findings are consistent with the research conducted by (Beyazıt et al., 2023). And disagree with the result of (Mazloomi et al.,2023).

This differences in the result due to the condition or the state of patient cases because the sample collected from patient who under treatment with metformin that causes to reduce the estrogen level in patient. Many studies showed that metformin, when used to treat PCOS, significantly reduced serum androgen levels, improved insulin sensitivity, restored menstrual cyclist, and was successful in triggering ovulation (Safiri et al., 2022).  Moreover, metformin can make menstrual cycles more regular and improve fertility (Attia et al.,2023

Table (2): Distribution Of The Patients With PCOS And Control group According to  Age, BMI And Estradiol.

PCOS= poly cystic ovary syndrome , SD= standard deviation

The Basic Clinical And Socio-demographic Characteristics Of Study Groups 

 Table (3) below illustrates that, based on PCOS groupings, there were 46(76.67%) suspected infertile women and 14(23.33%) fertile women. In contrast, the control group had 0(0.0%) infertile women and 60(100%) fertile women. Between PCOS patients and the control group, there was a significant difference (P-value <0.001). This outcome was consistent with research conducted by (Al-Musawy et al., 2018 and Ramanand et al., 2023).

The current study included only married, fertile, and healthy women as control participants. Infertility is a growing social problem, which is why the World Health Organisation (WHO) identified it as a civilization disease of the 21st century. It was also confirmed that patients with PCOS are more likely to report infertility and seek fertility treatment than those without. (Moss et al., 2024). PCOS is among the most common causes of infertility.(Attia et al., 2023; Safiri et al., 2022).

According to the results of the current study, of the PCOS patients, 19(31.67%) had regular menses, and 41(68.33%) had irregular menses (oligomenorrhea and amenorrhoea). Within the control group of the same study, 55 women (91.67%) reported regular menstruation, while 5 women (8.33%) reported irregular menstruation. Between PCOS patients and the control group, there was a significant difference (P-value < 0.05). 

 The results of this study are consistent with those of studies conducted by (Barrouq et al., 2023) which found that irregular menses (oligomenorrhea and amenorrhoea) were 12(11.4%) and regular menses 93(88.6%) and studies conducted by (Tabassum et al., 2021) which found that irregular menses were 99(99%) and regular cycles were 1(1.0%), while healthy control in which regular cycle was 192 (96.0%), irregular were 8(4%). These differences might be due to low sample size and medication.

On the other hand, in patients with polycystic ovarian syndrome, there were 40(66.67%)  hirsutism women and 20(33.33%) non-hirsutism women; in the control group, there were 0(0.0%) hirsutism women and 60(100%) non-hirsutism women. Between PCOS patients and the control group, there was high significant difference (P>0.001). These findings were in accordance with a number of investigations, including one by (Nahar et al., 2017), agreed with the research conducted by (Ramanand et al., 2013), significantly greater than the results reported by (Yousouf et al., 2012 and Joshi et al., 2017).

 A common ailment among women, hirsutism is a key clinical characteristic of polycystic ovarian syndrome (PCOS). This finding suggests that hirsutism, which might differ depending on one's ethnicity, is a significant clinical symptom of polycystic ovarian syndrome (Oliveira et al., 2024). 

 Hirsutism is considered to be a result either of increased testosterone production or increased follicular androgen sensitivity. Androgenic steroids, testosterone and dihydrotestosterone (DHT), are responsible for the transformation of vellus hair to terminal hair on the face, chest, lower abdomen, lower back, upper arms and thighs. Increased androgen levels during puberty transform vellus hair to terminal follicles of larger size and diameter, which have a longer lasting active growing phase (Armata et al., 2024).

 Also indicate that Polycystic ovaries was the most common causes of hirsutism followed by hyperprolactinemia, thyroid disease, congenital adrenal hyperplasia, and other idiopathic conditions (Ansari et al., (2024).

 The results also showed, the number of the women with acne were 33(55.0%), and the number of the  women without acne reached 27(45.0%), while in the control group, the number of women with acne were 10(16.67%) and women without acne 50(83.33%).  There was a significant difference between PCOS patients and control group (P>0.05). The result of this study agreement with the result of the study by (Barrouq et al.,2023). 

 Also these results agreed with a study by (Christodoulopoulou et al., 2016) in which (56.4%) had acne. And disagree with the study by (Moini et al., 2009) found acne in (25.64%) ,and the study of (Nahar et al., 2017), who reported 31(31.0%) had acne and a study by (Sangabathula et al.,2017), found that 21(21.0%) had acne.The differences in these results may be due to the small volume of samples in this study. 

The results of the study also as shown in Table (3) below, shows the results of women with PCOS frequently experience stress and anxiety, yet these conditions are frequently disregarded and go untreated. In the present study for PCOS patients was 54(90%) based on questionnaire form and non-stress was 6(10%) , while  the control group have stress was 10(16.67%) and non-stress was 50(83.33%). 

 The study found that women with PCOS had significantly higher stress levels compared to those without PCOS (P>0.05). The result of our study agreed with study of (Altaf et al., 2023) and the study of (Khafagy et al., 2020), that demonstrated that there is significant differences between PCOS group and control group. 

 The women may have high levels of stress and anxiety for a variety of reasons, including hirsutism, alopecia, infertility, and obesity, which is the main factor elevating mental stress levels. Over time, these conditions cause these women to experience depression. Insulin resistance and depression are linked to variables like low serotonin and high cortisol levels. The side effects of PCOS include elevated blood sugar levels and cortisol release, which prevent insulin's beneficial effects and cause insulin resistance in PCOS women(Rasgon et al., 2003; Sadeeqa et al., 2018).

Table (3) below shows that the education level of PCOS patients in the current study was {36(60%), 14(23.33%) and 10(16.67%)} for primary school, secondary school, and graduated, respectively, as compared to the control group {7(11.67%), 18(30%) and 35(58.33%)}. 

 The study's findings agreed with those of (Altaf et al., 2023), who found 14 (13.3%) at the intermediate level, 67(63.8%) undergraduates, and 24 (22.9%) graduates. The results disagree with the study of (Barrouq et al., 2023) in which the majority of participants had completed a university degree (32.4%), (31.4%) had completed high school, (20%) had completed middle school, and (2.9%) had completed primary school. This difference in results is due to differences in Social communities, as well as the country's economic conditions and wars.   

The results of  our study also showed, the number of housewives were 45(75.0%), and employers were 15(25.0%), while in the control group, the number of housewives were 39(65.0%), whereas the employers were 21(35.0%). 

There was no significant difference between PCOS patients and control group  (P-value <0.05). These result agreed with several studies, such as a study by (Altaf et al., 2023) in which the Unemployed 84(80.0%) and Employed 11(10.5%), (Hussein et al., 2013), which revealed the number of a housewife in PCOS patients were 89(84.0%) and employed 17(16.0%), while in the control group, housewife were 182(85.0%) and employed were 32(15.0%). This difference in results is due to differences in social communities, as well as the country's economic and educational conditions and wars.

 Regarding to Metaformin treatment, the current study showed that 91.67% of PCOS women and 8.33% healthy control group were used metaformin treatment.     

 Metformin is a recommended first step for managing PCOS in overweight or obese patients, particularly when oral contraceptives are not suitable or insulin resistance is evident (Nowak et al., 2024). Metformin is an effective treatment for anovulation in women with polycystic ovary syndrome. Its choice as a first line agent seems justified, and there is some evidence of benefit on variables of the metabolic syndrome. It should be used as an adjuvant to general lifestyle improvements and not as a replacement for increased exercise and improved diet (Lord et al., 2003).

Also, Menstrual cyclicity is increased as a result of the use of metformin, which also enhances the decrease in androgen circulation and ovulation. Weight loss is considered a factor that influences metabolic advantages (Safiri et al., 2022).

Table (3): Illustrate The Basic Clinical And Socio-Demographic Characteristics Of Study Group.

No.= count , PCOS= poly cystic ovary syndrome

Our study underscores the critical role of socio-demographic factors in the prevalence and manifestation of polycystic ovarian syndrome (PCOS) in Iraq. Our findings highlight the influence of education, stress, family history, obesity, physical activity, and infertility on the development and impact of PCOS in this population.

Conflict of Interest: None.

Acknowledgements: We thank the collage of science, Department of biology for the facility provided

Ethics of Study: Informed consent was obtained from each participant. The purpose and significance of the study were explained to the women. The privacy of any information gathered was guaranteed.

1. Al-Musawy, S. H., Al-Saimary, I. E., & Flaifil, M. S. (2018). Levels of cytokines profile in polycystic ovary syndrome. Medical Journal of Babylon, 15(2), 124-128.‏

2. Altaf, K., Mehreen, K., Khatoon, B., & Tariq, M. (2023). Role of Stress in Onset of Polycystic Ovarian Syndrome (PCOS). Journal of Health and Rehabilitation Research, 3(2), 1122-1127.‏

3. Ansari, R. T., Syed, U., Riaz, M., Askari, S., & Anjum, S. (2024). Unveiling the spectrum: A cross-sectional exploration of hirsutism causes in women. Pakistan Journal of Medical Sciences, 40(4).‏

4. Armata, I., & Prakash, A. (2024). An update on the assessment and management of hirsutism. Obstetrics, Gynaecology & Reproductive Medicine.‏

5. Barrouq, D. M., Alazawa, Z. F. R., & Irshaidat, T. (2023). Awareness of Polycystic Ovarian Syndrome among Jordanian Females. Open Access Indonesian Journal of Medical Reviews, 3(3), 429-436.‏

6. Beyazıt, F. A. T. M. A., Çiçekliyurt, M. E. L. İ. H. A., Turkon, H., Ünsal, M. E. S. U. T., & Pek, İ. B. R. A. H. İ. M. (2023). CTLA4+ rs231775 gene polymorphism increases PCOS, regardless of the levels of interleukin-6 and tumor necrosis factor-α in the serum. ANNALS OF CLINICAL AND ANALYTICAL MEDICINE, 8(14).‏

7. Cherian, K. E., & Paul, T. V. (2024). Management of insulin resistance in PCOS. In Metabolic Syndrome (pp. 407-413). Academic Press.

8. Christodoulopoulou, V., Trakakis, E., Pergialiotis, V., Peppa, M., Chrelias, C., Kassanos, D., & Papantoniou, N. (2016). Clinical and biochemical characteristics in PCOS women with menstrual abnormalities. Journal of Family & Reproductive Health, 10(4), 184.‏

9. Hashmi, M. F. (2024). Introduction to polycystic ovary syndrome. In Polycystic Ovary Syndrome (pp. 1-5). Elsevier.

10. Hussein, B., & Alalaf, S. (2013). Prevalence and characteristics of polycystic ovarian syndrome in a sample of infertile Kurdish women attending IVF infertility center in maternity teaching hospital of Erbil City. Open Journal of Obstetrics and Gynecology, 2013

11. Joshi, A. M., Yonzon, P., & Tandukar, S. (2017). Clinical profile of patients with polycystic ovarian syndrome in Nepal. Endocrinol Metab Int J, 4(2), 00083.‏

12. Khafagy, G., El Sayed, I., Abbas, S., & Soliman, S. (2020). Perceived stress scale among adolescents with polycystic ovary syndrome. International journal of women's health, 1253-1258.‏

13. Lentscher, J. A., & Decherney, A. H. (2021). Clinical presentation and diagnosis of polycystic ovarian syndrome. Clinical obstetrics and gynecology, 64(1), 3-11.‏

14. Lord, J. M., Flight, I. H., & Norman, R. J. (2003). Metformin in polycystic ovary syndrome: systematic review and meta-analysis. Bmj, 327(7421), 951.‏

15. Mazloomi, S., Barartabar, Z., & Pilehvari, S. (2023). The Association Between Increment of Interleukin-1 and Interleukin-6 in Women with Polycystic Ovary Syndrome and Body Mass Index. Journal of Reproduction & Infertility, 24(1), 26.‏

16. Moini, A., Shirzad, N., Ahmadzadeh, M., Hosseini, R., Hosseini, L., & Sadatmahalleh, S. J. (2015). Comparison of 25-hydroxyvitamin D and calcium levels between polycystic ovarian syndrome and normal women. International Journal of Fertility & Sterility, 9(1), 1.‏

17. Moss KM, Doust J, Copp T, Homerc H, Mishra GD. Fertility treatment pathways and births for women with and without polycystic ovary syndrome – a retrospective population linked data study. Fertil Steril 2024;121:314–22.

18. Moss, K. M., Doust, J., Copp, T., Homer, H., & Mishra, G. D. (2024). Fertility treatment pathways and births for women with and without polycystic ovary syndrome—a retrospective population linked data study. Fertility and Sterility, 121(2), 314-322.

19. Nahar, K., Mahfuza, G., Begum, S. A., Khatun, K., & Islam, M. R. (2017). Clinical, biochemical and hormonal profile of polycystic ovary syndrome. J Nat Inst Neurosci Bangladesh, 3, 94-8.‏

20. Nassif, D. S., Januário, B. L., Sousa, B. A., Thabane, L., & Abbade, J. F. (2024). Effectiveness of metformin to pregnant women with PCOS to reduce spontaneous abortion and gestational diabetes mellitus: a protocol for an overview of reviews. BMJ Open, 14(3), e078217.

21. Nautiyal, H., Imam, S. S., Alshehri, S., Ghoneim, M. M., Afzal, M., Alzarea, S. I., ... & Kazmi, I. (2022). Polycystic ovarian syndrome: a complex disease with a genetics approach. Biomedicines, 10(3), 540.‏

22. Nisa, K. U., Tarfeen, N., Mir, S. A., Waza, A. A., Ahmad, M. B., & Ganai, B. A. (2024). Molecular mechanisms in the etiology of polycystic ovary syndrome (PCOS): a multifaceted hypothesis towards the disease with potential therapeutics. Indian Journal of Clinical Biochemistry, 39(1), 18-36.

23. Nowak, K., Olejarz, Z., Drygała, Z., Wyrwał, J., Zielińska, Z., Słowik, M., ... & Krasuska, M. (2024). Role of Metformin in Polycystic Ovary Syndrome. Journal of Education, Health and Sport, 52, 131-144.‏

24. Oliveira, T. F., & Comim, F. V. (2024). Understanding hirsutism in PCOS. Expert Review of Endocrinology & Metabolism, (just-accepted).‏

25. Ramanand, S. J., Ghongane, B. B., Ramanand, J. B., Patwardhan, M. H., Ghanghas, R. R., & Jain, S. S. (2013). Clinical characteristics of polycystic ovary syndrome in Indian women. Indian journal of endocrinology and metabolism, 17(1), 138-145.‏

26. Rasgon,N.L.; Rao,R.C.; Hwang,S.;Altshuler, L.L., Elman, S.; Zuckerbrow-Miller, J. & Korenman, S. G. (2003). Depression in women with polycystic ovary syndrome: clinical and biochemical correlates. J of affective disorders, 74(3), 299-304.

27. Sachdeva, G., Gainder, S., Suri, V., Sachdeva, N., & Chopra, S. (2019). Obese and non-obese polycystic ovarian syndrome: Comparison of clinical, metabolic, hormonal parameters, and their differential response to clomiphene. Indian journal of endocrinology and metabolism, 23(2), 257-262.‏

28. Sadeeqa, S.; Mustafa, T., & Latif, S. (2018). Polycystic ovarian syndrome related depression in adolescent girls: A Review. J. of pharmacy & bioallied sciences, 10(2), 55.

29. Safiri, S., Noori, M., Nejadghaderi, S. A., Karamzad, N., Carson-Chahhoud, K., Sullman, M. J., ... & Avery, J. (2022). Prevalence, incidence and years lived with disability due to polycystic ovary syndrome in 204 countries and territories, 1990–2019. Human Reproduction, 37(8), 1919-1931.‏

30. Sangabathula, H., & Varaganti, N. (2017). Clinical profile polycystic ovarian syndrome-100 cases. Int J Contemporary Med Res, 4(6), 1249-53.‏

31. Sarhat, E. R., Abid, I. M., Kamel, N. A., Sarhat, T. R., & Abass, K. S. (2021). Changes of serum Interleukin and Chemerin levels in patients with Polycystic Ovary syndrome. J Adv Pharm Educ Res Oct-Dec, 11(4), 11-14.‏

32. Shrivastava, S., & Conigliaro, R. L. (2023). Polycystic ovarian syndrome. Medical Clinics, 107(2), 227-234.

33. Tabassum, F., Jyoti, C., Sinha, H. H., Dhar, K., & Akhtar, M. S. (2021). Impact of polycystic ovary syndrome on quality of life of women in correlation to age, basal metabolic index, education and marriage. PloS one, 16(3), e0247486

34. Yousouf, R., Khan, M., Kounsar, Z., Ahangar, S., & Lone, W. A. (2012). Polycystic ovarian syndrome: clinical correlation with biochemical status.‏