Polycystic Ovarian Syndrome is a multifaceted endocrine disorder characterized by ovarian cysts, anovulation, and hormonal fluctuations, significantly impacting a woman's life, with a prevalence rate of 6.6–6.8%[1,2]. The signs and symptoms of this condition include irregular or absent menstrual cycles, clinical or biochemical hyperandrogenism, infertility, and insulin resistance, which lead to hyperinsulinemia and alterations in the metabolic profile [3,4]. Haemoglobin A1c (HbA1c) is the primary measure for evaluating average glycaemic management. It indicates the ratio of hemoglobin molecules that are conjugated with glucose. Increased HbA1c readings signify elevated glucose levels over the past 2-3 months. Thus, a HbA1c test is essential for assessing average glucose levels in diabetic individuals and, when elevated, assists in diagnosing the illness [5]. Luteinizing hormone (LH), also known as luteinising hormone or lutropin, and follicle-stimulating hormone (FSH) are glycoprotein polypeptide hormones generated by gonadotropic cells in the anterior pituitary gland. Their secretion is modulated by gonadotropin-releasing hormone (GnRH) produced in the brain [6]. FSH is crucial for regulating development, growth, pubertal maturation, and reproductive functions, while FSH and LH work in conjunction within the reproductive system. The sudden elevation of LH in females, known as the LH surge, initiates ovulation and the formation of the corpus luteum. Free radicals are produced in both healthy and diseased conditions inside mammalian tissues [7]. The unregulated generation of free radicals is considered a significant contributor in tissue damage associated with different pathophysiological illnesses[8]. The predominant free radicals in cells that induce oxidative stress include the superoxide radical, hydroxyl radical (OH), hydrogen peroxide radical (H2O2), nitric oxide radical (NO), and peroxynitrite radical (ONOO). Reactive oxygen species (ROS) are extensively recognized for their harmful impact on biological constituents, including lipids, proteins, and nucleic acids, resulting in cellular destruction[8,9]. As a result, reports of reactive oxygen species (ROS) are frequently linked to several human diseases, such as cancer, neurological disorders, chronic inflammation, cardiovascular disease, and aging [10]. Dietary and endogenous antioxidants provide an effective antioxidant system that alleviates the impact of reactive oxygen species (ROS). The aim of this study was to assess antioxidant levels and oxidative stress in Iraqi people diagnosed with polycystic ovarian syndrome.

2.1. Subjects: 

This research involving 90 samples (60 women with PCOs and 30 healthy women) conducted in Tikrit Governorate from late December 2023 to the end of April 2024, focusing on individuals aged 20-50 years, with 60 patients (females) severely affected by polycystic ovary syndrome aged 15-45 years. A control group of 30 females without polycystic ovary syndrome was established. Laboratory tests were performed on both groups to assess the levels of GSH and MDA, utilizing ELISA for estimation, along with HbA1c, LH, FSH, and testosterone measurements.

2.2. Exclusion Criteria: 

Individuals without polycystic ovarian syndrome, females over 45 years old, and those afflicted by these conditions: Type II diabetes, hyperlipidemia, and obesity

2.3. Sample collection

For both study groups, 5 milliliters of venous blood were drawn. The blood sample was separated into two portionss. The first part, 3 milliliters, was placed in gel tubes and the blood was permitted to coagulate, and then the serum was separated using the centrifugation for 10 minutes at 3000 rpm, the serum was stored in a 1.5 ml Eppendorf tube at a temperature of - 20 C° until the biochemical and hormonal tests are conducted. The remaining part (2 ml) was placed in an EDTA tube and left on a mixer for several minutes to prevent any coagulation, then the Hemoglobin A1 c (HbA1c) test was performed for all samples. Furthermore, to measuring the levels of several sex hormonal tests such as LH, FSH, and testosterone automatically through using Roche e411 autoanalyzer (Roche company, Germany). While the level of GSH and MDA hormone was estimated via using the commercial ELISA kit (CloudClone Corp., USA).

The ANOVA test showed group variable differences. The linear relationship between features was examined using correlation analysis. The Student T-Test examined mean value fluctuation importance. A probability of P ≤ 0.05 implies significance, while P > 0.05 suggests non-significant.

This study showed increased LH, Testosterone, and HbA1_c in women with PCOs that were (11.26±4.58, 0.93±1.77, 5.54±0.47)as compared with Healthy women that were (5.71± 3.95, 0.38±0.2, 4.12±0.73 ) respectively at p-value <0.05. While no differences in FSH level between women with PCOs and Healthy women that were (8.11±3.15, 8.75± 2.91) respectively at p-value >0.05.

Table (1):Level of FSH, LH, Testosterone and HbA1_c  between study groups

The level of glutathione  was evaluated in the serum of women with PCOS as compared with healthy women that were (15.49±2.99, 21.93±3.14 ) respectively at p-value< 0.05.Also decrease level of Vitamin C in PCOS as compared with healthy women that were (1.13±0.13, 1.25±0.19) respectively at p-value < 0.05. While increase level of MDA in PCOS as compared with healthy women that were (31.67±3.53, 17.23±1.23) respectively at p-value > 0.05.

Table (2):Level of Glutathione, Vitamin C and Malondialdehyde between study groups

In the current study, the levels of LH and testosterone were found to be considerably higher in the PCOS group when compared to the control group. On the other hand, the levels of FSH were found to demonstrate a non-significant increase in the PCOS group when compared to the control group. The current study is consistent with the references [12,13], which also demonstrated that people of color have increased levels of sex hormones. Elevated adrenal androgen levels combined with adipose tissue result in enhanced extraglandular estrogen production by peripheral aromatization. The increased concentration of estrogen promotes positive feedback on LH secretion and negative feedback on FSH secretion (14). In clinical practice, testosterone is the main indicator of female hyperandrogenism. The ovaries directly manufacture it or through androstenedione metabolism in adipose or peripheral tissues. A previous study indicating elevated testosterone levels in PCOS patients, highlighting the significant role of testosterone in PCOS.  The current investigation revealed a statistically significant elevation in the mean HbA1c % level among women with PCOS compared to the control group, consistent with [16]. Our investigation revealed elevated HbA1c values in the PCOS group, signifying inferior glycemic management and increased insulin resistance relative to the control group. This discovery aligns with the documented correlation between PCOS and an elevated risk of type 2 diabetes and metabolic syndrome. Insulin resistance is a fundamental aspect of the pathophysiology of PCOS, leading to hyperandrogenism and ovarian dysfunction [17,18,19,20].These findings underscore the necessity of monitoring and regulating blood glucose levels in women with PCOS to avert long-term problems. 

Lipid peroxidation produces MDA, a byproduct that functions as a biomarker to determine the degree of lipid peroxidation. As markers for oxidative stress, compounds resulting from lipid peroxidation processes have been widely used[21]. This study shows that when compared to healthy controls, PCOS patients had significantly higher serum MDA levels. This is consistent with the results of [22], which showed that people with PCOS had significantly higher serum MDA levels than the controls. further [23]obtained data linking insulin resistance and hyperglycemia in PCOS to the rise in MDA. As a result, increased ROS generation as a result of the participants' severe oxidative damage may result in raised MDA levels. Membrane lipids are among the many other significant biomolecules that these oxygen species have the ability to oxidize. 

Vitamin C is a type of non-enzymatic antioxidants, nonsoluble in water. It is the main cofactor that needed for some metabolic process in addition it is the most important antioxidants for free radicles in lipid peroxidation. This study showed decrease in vitamin C, that agree with[22, 24]. PCOS patients' endometrial tissue and peritoneal fluid had significantly lower Vitamin C levels, according to Polak et al. [25]. The significant drop may be due to vitamin C depletion during free radical neutralization. Living cells need GSH, a tripeptide antioxidant that scavenges intracellular radicals. This study shows that PCOS patients had considerably lower serum GSH levels than controls. The results support [26,27], which found that PCOS patients had lower GSH levels than controls, suggesting that insulin resistance may be indirectly linked to GSH deficiency. Hyperglycemic glucose intake via the polyol route, which requires nicotinamide adenine dinucleotide phosphate for GSH regeneration via the GSH-reductase enzyme, may lower GSH levels. Thus, insulin resistance-related hyperglycemia in PCOS may indirectly deplete GSH, increasing oxidative stress. 

In conclusion, women with PCOS exhibited elevated levels of oxidative stress. This study's findings indicate oxidative stress in PCOS, evidenced by increased generation of oxygen free radicals and diminished antioxidant activity. An adaptive response to heightened oxidative stress may be observed through the augmented activity of antioxidant enzymes. In conjunction with established risk factors such as insulin resistance, hypertension, central obesity, and dyslipidemia, a reduction in antioxidant capacity may elevate the risk of cardiovascular disease in women with PCOS. The growth regulation of ovarian mesenchyme may be influenced by reactive oxygen species. Ovarian mesenchymal hyperplasia may arise from elevated oxidative stress and diminished antioxidant levels in pathological conditions such as PCOS. Timely disease identification and antioxidant supplementation may serve as an effective adjunctive treatment to mitigate oxidative damage.

The authors declare that they have no conflict of interest

No funding sources

The study was approved by the General Direction Of Education in Salah al-Din, Iraq

1. Evanthia, Diamanti-Kandarakis, Charikleia, D., Christakou, E. K. and Frangiskos, N. E. (2010). Metformin an old medication of new fashion evolving new molecular mechanisms and clinical implications in polycystic ovary syndrome. European Journal of Endocrinology. 162: 193-212.

2. Tapanainen, J.S. et al. (2008). Effective regimens for ovulation induction in polycystic ovary syndrome Current Controversies from the Ovary to the Pancres Totowa. N. J. Humana. 15:7- 307.

3. Azziz, R. (2006). Diagnosis of Polycystic Ovarian Syndrome: The Rotterdam Criteria Are Premature. Journal of Clinical Endocrinology & Metabolism. 91: 3: 781–785.

4. Nahar, K. (2019). Polycystic Ovary Syndrome in Teenage and Young Women. Journal of Bangladesh College of Physicians and Surgeons, 37(2): 78-82.

5. Klonoff, D. C. Hemoglobinopathies and hemoglobin A1c in diabetes mellitus. Journal of diabetes science and technology, 14(1), 3-7. 2020. 

6. Mahmoud, H. Q., Mhana, R. S., & Mohammed, A. A. (2024). Therapeutic options and management approach on thalassemia an overview. International Journal of Medical Science and Dental Health, 10(01), 17-28. 

7. Santi, D., Crépieux, P., Reiter, E., Spaggiari, G., Brigante, G., Casarini, L., ... & Simoni, M.. Follicle-stimulating hormone (FSH) action on spermatogenesis: a focus on physiological and therapeutic roles. Journal of Clinical Medicine, 9(4), 1014. 2020. 

8. Sengupta, P., Arafa, M., & Elbardisi, H. Hormonal regulation of spermatogenesis. In Molecular signaling in spermatogenesis and male infertility (pp. 41-49). CRC Press. 2019.

9. NAEEMAH, Helen; SAHSAVARI, Zahra; MOHAMMED, Mustafa Taha. ESTIMATION OF REACTIVE OXYGEN SPECIES AND TOTAL ANTIOXIDANT CAPACITY IN SERUM OF IRAQI FEMALES WITH PCOS. Turkish Journal of Physiotherapy and Rehabilitation, 2021, 32: 3.‏

10. AL-AZZAWIE, Hasan F.; HUMADI, Esraa Hameed. Oxidative Stress and the Antioxidant Mechanisms in a Sample of Iraqi Patients with Polycystic Ovary Syndrome (POS). IRAQI JOURNALOF COMMUNITY MEDICINE, 2010, 23.3.‏

11. Chandra R, Aneja R, Rewal C, et al (2000).An opium alkaloid papaverine ameliorates ethanol induced hepatotoxicity: diminution of oxidative stress”, Indian Journal of Clinical Biochemistry, 15(2), p:155-60.

12. HASAN, Suha Sabri. Evaluation of Vaspin Levels and Some Biochemical Variables in poly cystic Ovary Syndrome Patients in Diyala Governorate. 2021. PhD Thesis. College of Science Department of Chemistry Evaluation of Vaspin Levels and Some Biochemical Variables in poly cystic Ovary Syndrome Patients in Diyala Governorate A Thesis Submitted to the Council of the College of Science, University of Diyala.‏

13. SHAMEL, Sara; KARA, Ozlem; ABBAS, Ali. Investigation of some fertility indicators in Iraqi women with polycystic ovary syndrome. International Innovations Journal of Applied Science, 2024, 1.spc.‏

14. Racoubian, E., Aimagambetova, G., Finan, R. R., & Almawi, W. Y. (2020). Age-dependent changes in anti-Müllerian hormone levels in Lebanese females: correlation with basal FSH and LH levels and LH/FSH ratio: a cross-sectional study. BMC Women's Health, 20(1), 1-6.

15. Kloner, R. A., Carson, C., Dobs, A., Kopecky, S., &Mohler, E. R. (2016). Testosterone and cardiovascular disease. Journal of the American College of Cardiology, 67(5), 545-557.

16. AL-JUMAILI, Farah TO; NAJI, Aqeel Jafar; JASIM, Thamer Mutlag. Evaluation of Some Biochemical Markers in Patient's with Polycystic Ovarian Syndrome. Journal of Biotechnology Research Center, 2015, 9.2: 37-45.‏

17. Chen H, Zhang Y, Li S, et al. The genetic association of polycystic ovary syndrome and the risk of endometrial cancer: a Mendelian randomization study. Front Endocrinol (Lausanne). 2021; 12:756137. 

18. Bulsara, J.; Patel, P.; Soni, A.; Acharya, S. A review: Brief insight into Polycystic Ovarian syndrome. Endocr. Metab. Sci. 2021; 3: 100085.

19.  Ding, H., Zhang, J., Zhang, F., Zhang, S., Chen, X., Liang, W., Xie, Q. Resistance to the Insulin and Elevated Level of Androgen: A Major Cause of Polycystic Ovary Syndrome. Front. Endocrinol. 2021; 12: 741764.

20.  Marshall, J.C.; Dunaif, A. Should all women with PCOS be treated for insulin resistance? Fertil Steril . 2012; 97: 18–22.

21. OYEBANJI, Olufisayo Grace; ASAOLU, Modupe Fisayo. Assessment of antioxidant status of women with polycystic ovarian syndrome. Asian Pacific Journal of Reproduction, 2020, 9.1: 9-15.‏

22. Zhang D, Luo WY, Liao H, Wang CF, Sun Y. The effects of oxidative stress to PCOS. Sichuan Da Xue Xue Bao Yi Xue Ban 2008; 39(3): 421-423.

23. Kuscu NK, Var A. Oxidative stress but not endothelial dysfunction exists in non-obese, young group of patients with polycystic ovary syndrome. Acta Obstet Gynecol Scand 2009; 88(5): 612-617.

24. Surapaneni KM, Vishnu PV. Lipid peroxidation, glutathion, ascorbic acid, vit E, antioxidant enzyme and serum homocysteine status in patients with polycystic ovary syndrome. Biol Med 2009; 1(3): 44-49.

25.  Polak G, Kozioł-Montewka M, Gogacz M, Błaszkowska I, Kotarski J. Total antioxidant status in peritoneal fluid in infertile women. Eur J Obstet Gynecol Reprod Biol 2001; 94: 261-263.

26. Dincer Y, Akcay T, Erdem T, IlkerSaygili E, Gundogdu S. DNA damage, DNA susceptibility to oxidation and glutathione level in women with polycystic ovary syndrome. Scand J Clin Lab Invest 2005; 65(8): 721- 728.

27. Sabuncu T, Vural H, Harma M, Harma M. Oxidative stress in polycystic ovary syndrome and its contribution to the risk of cardiovascular disease. Clin Biochem 2001; 34(5): 407-413.