Polycystic ovarian morphology or Polycystic ovarian syndrome (PCOS), termed in common parlance as the “The thief of womanhood” has emerged in recent  times as a spectrum of disorders starting from menorrhagia, hirsutism to infertility. 1 The disorder not just carries with it the stigmata of reproductive disorders but also linked with various metabolic risks including insulin resistance and dyslipidemia.2 Though not much appreciated in developing countries, the problem is growing at an alarming pace within sub-continental community with prevalence touching up to 9% of the population in young females. 3

Literature review provides variable results in terms of PCOS association with clinical and metabolic risk factors. Firstly, researchers have discovered different phenotypes of PCOS as regards to their clinic-pathological correlates, which vary as per the geographical zone one belongs to. 4The usual diagnosis revolves around establishing not just the clinical presentation including disturbances in a menstrual cycle like oligo or anovulation, but reliance has been placed on various biochemical, endocrine parameters and radiological findings for labeling   subjects with PCOS. 5 Secondly, there is data to support that available evidence is suggestive of inconsistent data regarding biochemical and endocrine parameters, probably due to inherent imprecision related to analytical techniques or rapidly changing hormonal cycle within the females. 6 Finally, multiple criteria starting from NIH from 1992, to Rotterdam and AE-PCOS are available to define PCOS, but yet consensus among authorities in far from converging to a common solution. 748 Furthermore, local data apart from its scarcity, still has been able to identify differences in phenotype especially for the sub-continental population. 9 While the clinical presentations due to symptoms vary across the cultures, authorities in past have been suggesting a simpler way to diagnose or suspect PCOS, where the role of anthropometric measurements can play a major role especially in resource- scarce countries. 10 Earlier studies in this Pazderska et al have indirectly shown waist circumference to predict cardiometabolic disease in subjects with PCOS thus highlighting the usefulness of anthropometry in this condition. 11 Another Chinese study by Huang et al identified anthropometric indices and lipid peroxidation products to be useful in identifying the underlying risk in PCOS. 12Techatraisak et al have identified visceral adiposity index and other related measures like BMI to have the potential of predicting PCOS. 13 In recent times we had several new anthropometry based indices along with conventional parameters and anthropometric measures and biochemical mathematical equations which we as author feel can potential our diagnostic tool s to predict one of the commonest disorders affecting female fertility and onward a source to cardiometabolic risk.

In the backdrop of shared evidence regarding anthropometric measures as candidate surrogate markers for diagnosing PCOS, cost-effectiveness in relation to developing and under-developed worlds and emergence of some new anthropometric measures with probable higher yields we decided to carry out a study to see the utility of various anthropometric measures and PCOS. The objective will be to compare traditional measures like waist to hip and height ratio (WHpR and WHtR), BMI, newer markers depicting central obesity like visceral adiposity index(VAI), Abdominal Volume index(AVI), Body roundness index (BRI), A Body Shape Index (ABSI), Conicity index (C-index) along with biochemical-anthropometric equations like lipid peroxidation for diagnosing PCOS as per the Rotterdam criteria.

This cross-sectional survey was conducted at the department of gynecology & obstetrics, pathology and Radiology departments of Naval Hospital Islamabad from Jan-2018 to July-2019. The project “PCOS study” has the formal approval of “Hospital’s ethical review committee” who monitored the study throughout its course of conduct. Final signed “Ethical approval letter” was issued at the end of the study. The target population was non - pregnant female subjects who presented at the department of gynecology or female out-patient departments with history of menstrual disturbances. Subjects who had history of any chronic disease process like autoimmune disorder, metabolic ailments on medication like diabetes, hypertension, heart disease, presenting within two years of menarche, using oral contraceptive in the last 6 months, or had any hormonal fertility treatment and acute or chronic infectious disease process were excluded from the study. They were requested to participate in the study by coming to department of pathology in “exact medical fasting status” during 2^nd day of follicular phase of their menstrual cycle. On the day of arrival at pathology department the ladies were explained about the study requirements, testing to be done and consequences of the study along with confidentiality of data. A total of 333 ladies consented by signing a written consent form, which was followed by a questionnaire- based interview. After interview, clinical examination was carried out for any signs of chronic disease, anthropometric measurements 14, degree of hirsutism as measured by modified Feriman- Gallwey score(mFG score) 15 and Free Androgen Index (FAI) by Total testosterone/SHBG x 100. Calculations were some new anthropometric measures including Abdominal Volume index (AVI), Body Roundness Index(BRI), A Body Shape Index (ABSI), Body Adiposity Index (BAI) and Conicity index(C-Index) were also done a per the given criteria. 1617181920 Visceral Adiposity Index (VAI), Chinese Visceral Adiposity  Index (CVAI) and Lipid Accumulation Products (LAP) were measured using as per standard criteria. 1213

10 ml blood was collected for measuring for various biochemical and endocrine parameters. After sampling patient went for radiological examination. PCOS was defined as per Rotterdam-define PCOS criteria. 12 Fasting plasma glucose, triglyceride and total cholesterol was measured by using GPO-PAP, GOD-PAP CHOD-PAP methods on Random Access Clinical Chemistry analyzer (Selecta Prom). LDLc and HDLc were measured direct enzymatic method where selective end-point method detergent and accelerator by using Merck Kit on Selecta Prom. Endocrine parameters including total testosterone and sex-hormone- binding globulin (SHBG) were analyzed on Chemiluminescent Microparticle Immunoassay (CMIA) on “ARCHITECT iSystem  , Abbot Diagnostics”.

Subjects who failed to follow up for various reasons (n=23) including not turning for on given menstrual cycle date, non-medical fasting status, or needing a sample repetition and not but not returning for testing or did not undergo ultrasonography due to any reason were finally excluded from study.

Mean age among our subjects was 27.89 (+ 7.62) years. Out of 333 subjects 93 were unmarried, while 238 subjects were married. History of anovulation was given by 205 patients while rest (n=128) did not give any menstrual cycle abnormality. Modified FG score was higher than or equal to 8 among 157 subjects in comparison to 175 ladies with less than 8 score out of the total designated 36 marks. 87 subjects were having radiological proven signs of PCOS, while 246 females did not show criteria defined PCOS signs in ovaries for PCOS. 169 females were diagnosed to have PCOS as per Rotterdam criteria against 164 who could not fulfill the criteria for PCOS. Hirsutism was found to be more prevalent in both subjects diagnosed to have PCOS either as per Rotterdam defined criteria or on ultrasonography. Figure 1 and Figure 2 Similarly free androgen index (FAI) was found to be raised in subjects with PCOS either defined by Rotterdam criteria or ultrasonography. Figure 3 and Figure 4 Lean PCOS demonstrated lower degree of hirsutism and biochemical hyperandrogenism in comparison to obese PCOS as depicted in Table 1, Table 2, Table 3, Table 4.

Our findings suggested that PCOS females demonstrated higher degree of clinical hyperandrogenism as measured by hirsutism and biochemical hyperandrogenism (Free Androgen Index) among patients diagnosed to have PCOS either by Rotterdam criteria or ultrasound alone. These findings are in accordance with multiple studies on PubMed. 212223 However, anthropometric measures including conventional, newer and mathematical models of biochemical and anthropometric measures did not demonstrated less rise in anthropometric measures among PCOS females than non-PCOS subjects especially for waist circumference, WHtR, BAI, BRI and AVI where the results were statistical significant. Lean PCOS females demonstrated slightly lower clinical and biochemical hyperandrogenism than obese PCOS subjects. This phenomena was in contrast to common belief that PCOS results due to extra fat accumulation or in some way associated with obesity as demonstrated in some studies. 24

Though Rotterdam defined PCOS criteria and radiological diagnosis of PCOS had significantly higher scores for clinical (modified FG cores for hirsutism) and biochemical hyperandrogenism (Free Androgen Index), still anthropometric measures the anthropometric measures or anthropometry couple biochemical equations did not show higher obesity indices among subjects with PCOS as per Rotterdam defined criteria indicating a lean-PCOS pattern in our studied population.

Ethical approval - The project “Hyperandrogenism, hirsutism and anthropometric profiles among subjects with polycystic ovarian morphology? A cross-sectional analysis” was approved by ethical review committee of the hospital. All participants signed “Informed Written Consent Performa” and were explained about the study project.

SPSS data outputs are available from corresponding author, if demanded.

SHK: (Corresponding author) Idea conception, Study plan, laboratory testing, result analysis, manuscript writing.

AAG: History writing, data analysis, medical writing.

RM: Study plan, sampling of subjects, statistical review and manuscript writing.

AHB: History, data analysis and manuscript help and contributed discussion.

RA: History writing, examination, medical writing

TC: Study plan, statistical review medical writing. All authors approved the final manuscript.

We got written consent and signs from all participants.

The study had no funding source to disclose.