REVIEW OF LITERATURE

The review of literature is defined as a broad, comprehensive, in-depth, systematic, and

critical review of scholarly publications, unpublished scholarly print materials, audio-
visual materials, and personal communications.

"Review of literature" refers to an extensive, exhaustive, and systematic examination of

publications relevant to the research project."

In the present study the researcher reviewed the literature under the following headings:

•Effect of lifestyle modification in PCOS prevention. • Alternative therapies for PCOS

treatment.

Effect of lifestyle modification in PCOS prevention.

1. A predictive correlation study was conducted to assess the effect of lifestyle

changes intervention among females with PCOS. A purposive sampling technique
used to select 50 samples for the study. Pre- and post-intervention subject
assessment was done. The intervention was administered in five sessions. Quality
of life and self-esteem were measured pre- and post-intervention. The study results
revealed that the knowledge of samples regarding polycystic ovary was improved
significantly post intervention; also, the incidence of obesity among subjects
decreased by 16% compared with 66% pre-intervention, and 96% of the subjects
had low self-esteem before the intervention, compared to 30 percent after 6 months
and just 20% after 12 months. There were also significant variations in the physical,
psychological, and social domains of quality of life pre- and post-intervention. The
study concluded that the lifestyle modifications have a positive effect on the quality
of life and self-esteem of the study participants'.
2. An explorative study was conducted to assess the awareness of lifestyle
modification in females diagnosed with polycystic ovarian syndrome in Navi
Mumbai India. Purposive method was used, and 100 samples were selected from
those who were visiting gynecological clinics around Mumbai and Navi Mumbai. A
self-made questionnaire validated by an expert was used for data collection. The
results of the study revealed that 21% of respondents are well aware, and 51% were
educated by a doctor about PCOS. 81.9% of study participants expressed that
PCOS is manageable, and 62% were aware that exercise helps in managing PCOS,
out of 39%, some were doing exercise on a regular basis, and 64% were aware of
changing diet or eating habits in the prevention of PCOS. 95% of subjects concurred
to follow lifestyle modification. The study concluded that efforts needed to intensify
 in creating awareness among the general public about PCOS. The majority of study
participants were not forced to follow lifestyle modification; however, emphasis
needed to be placed on a multidisciplinary approach in managing PCOS.36.
3. A cluster randomized clinical trial study was conducted to assess the effectiveness
of a lifestyle training program promoting adolescent health with polycystic ovarian
syndrome. 60 healthy adolescent girls and 60 PCOS adolescent girls, which will be
divided into four groups: intervention groups(30 PCOS +30 healthy) and control
groups(30 PCOS +30 healthy). Changes in primary and secondary outcomes in
PCOS and healthy adolescents before and after intervention in the intervention and
control groups will be analysed for evaluation effectiveness by one-way ANOVA or
other nonparametric equivalents. The current study will provide information on the
effectiveness of school-based lifestyle training programs for adolescents. With
increasing numbers of PCOS at risk for long-term and/or late effects of treatment
and other chronic diseases, efforts for promoting the healthy lifestyle of this
important group are urgently needed. This lifestyle program may provide valuable
information relating to the development of other healthy lifestyle interventions for
PCOS and result in appropriate behavior change and self-management strategies.
4. A qualitative phenomenology research was conducted to assess the
implementation of evidence-based PCOS lifestyle management guidelines:
perceived barriers and facilitators by consumers using the theoretical domains
framework (TDF) and the Capacity, Opportunity, Motivation, and Behavior model
(COM-B). 20 Australian women with PCOS were selected, and the data was
collected by semi-structured telephonic interview. The results of the study showed
nine themes mapped onto seven TDF domains and the COM-B. Capability:
psychological co-morbidities, knowledge and awareness of lifestyle change, and
ability to identify and resolve barriers. Opportunity:presence of other medical
conditions, access to practical resources, and availability of social support.
Motivation: outcome expectancies of lifestyle behavior, personal values, enjoyment,
readiness to change, and the impact of stress on lifestyle choices.38.

Alternative therapies used in the prevention of PCOS

5. A prospective observational study was conducted on gut microbiota and oral

contraceptives in overweight and obese patients with polycystic ovary syndrome.
The study was conducted in a tertiary referral hospital and included 17
overweight/obese patients with PCOS and 15 age- and body mass index-matched
healthy control women. The results revealed that alpha and beta diversity did not
show a difference between patients with PCOS and healthy controls at baseline and
remained unaltered after 3 months of OC use in the PCOS group. Relative
 abundance of Ruminococaceae was higher in PCOS (P = 0.06) and did not show a
significant change after treatment. The study concluded that women with PCOS
have an increased abundance of Ruminococaceae, whereas short-term OC use
does not alter compositional features of gut microbiota in the syndrome".
6. Quasi-experimental research was carried out at St. Meera's College and Wadia
College, Pune, to assess the effectiveness of an information booklet regarding
lifestyle modifications in polycystic ovarian disease among undergraduate arts &
science students. The study consisted of 100 samples, which were selected by non-
probability purposive sampling of undergraduate students. 50 from the science
stream and 50 from the arts stream were selected in the study. The study was
conducted in selected arts and Science colleges of the city. A self-administered
questionnaire was used and gathered data related to demographic data on 10
different variables and knowledge of PCOS and its treatment. The results revealed
improvement in the knowledge score of the students in the post-test score of the
study, and the information booklet was effective in increasing the knowledge of the
subjects regarding lifestyle modifications in polycystic ovarian disease.'0
7. A randomized controlled trial conducted on a pulse-based diet and the therapeutic
lifestyle changes diet in combination with health counselling and exercise improves
health-related quality of life in women with polycystic ovary syndrome. 61 samples
of 18-35-year-olds were selected by purposive sampling, out of which 30 women
were pulse-based and 31 were kept in the TLC group and completed a 16-week
intervention without energy restriction. The results concluded that both the
interventions improved health-related quality of life (HRQoL) scores in women with
PCOS without prescribed energy restriction.
8. A longitudinal study was conducted in Bhopal, M.P., on remote assessment and
reinforcement of patient awareness of the role of lifestyle modification and
treatment adherence in polycystic ovarian syndrome using an online video-based
educational module. Nonprobability Purposive sampling technique was used to
select 41samples who were diagnosed with PCOS. The samples' factual and
conceptual knowledge about disease and awareness behavior related lifestyle
modification and therapy compliance was assessed using a validated questionnaire
regarding awareness of lifestyle modification. The study results revealed 17.1% had
fair knowledge, 48.8% had moderate knowledge, and 34.1% had good knowledge
scores after the educational video module. The study concluded that the
educational module was found to be effective in significantly increasing the
knowledge about PCOS, and this knowledge will reinforce the message about
lifestyle modification.
9. A quasi-experimental study conducted to assess the implementation of an
awareness programme and lifestyle intervention on polycystic ovarian syndrome
among adolescent school girls in India. Simple randomized sampling technique was
adopted to select 120 samples from 10th to 12th standard. The tools used for data
collection were developed by the researcher and included a knowledge
questionnaire, which included 25 multiple-choice questions, and an attitude
questionnaire, which was a five-point Likert scale with a minimum of 0 and a
maximum of 4 scores, and scores were interpreted as most favorable attitude,
favorable attitude, and unfavorable attitude. The data was analyzed using SPSS, and
pre-test and post-test scores were assessed by an independent t-test. The results of
the study showed the improvement in knowledge and attitude scores upon
educational intervention. The study concluded that it is feasible to incorporate an
education module for school-going adolescent girls at risk for PCOS to help in early
identification and prevention of illnesses.
10. A randomized controlled trial was conducted on the effects of a structural
education module among women with polycystic ovarian syndrome on nutrition and
physical activity changes on female staff of the University Putra Malaysia who were
diagnosed with PCOS. 69 samples were assigned into intervention (n=34) and
control groups (n=35) by random block design sampling technique. In the
intervention group, they need to take part in 8 education sessions in total over 6
months, and feedback was collected at the end of the session. Demographic data
was collected by a self-administered questionnaire. Nutrition knowledge on food
groups, general nutrition knowledge, and the principle of energy balance and
healthy diet were estimated by two nutrition knowledge questionnaires (25 items),
and a 10-item questionnaire was designed to assess the attitude towards
consumption of a healthy diet, proper food choices, and weight reduction. The
study concluded that there was improvement of mean score for some aspects of
both nutrition and physical activity it not all improvement was significant. This
health education was found useful in guiding Malaysian women with PCOS to
improve their knowledge, attitude, and practice of diet and physical activity''.
11. True experimental research was conducted among adolescent girls belonging to
two government-run schools in the Tiruvallur district of Tamil Nadu state, India, on
the impact of yoga and exercises on polycystic ovarian syndrome risk among
adolescent schoolgirls. Nonprobability purposive sampling was used to select the
samples and 207 samples were selected but out of which due to dropout, only 204
were included for analysis, A standard risk assessment questionnaire was adopted
for risk assessment after making few modifications. The data was analyzed using
Statistical Package for Social Sciences (SPSS, version 16) and STATA (version 12)
 software and Epi info (version 3.5.1). Research finding concluded yoga and exercise
customized as per school girls schedule involving school teachers can have a
positive impact on PCOS risk reduction, As reported in the research, upon
interventions, a signi ficant risk reduction occured among the experimental group,
suggesting the usefulness of interventions. This study thus provides a foundation for
incorporating lifestyle interventions among adolescent school-going girls with PCOS
risk. Lifestyle modifications among school going adolescent girls may be a
successful strategy in PCOS risk minimization among the Indian population'".
12. A Single-binded, prospective, pre-post clinical trial study conducted to evaluate the
changes in polycystic ovarian morphology after naturopathic and yogic
interventions at the Government Yoga and Naturopathy Medical College and
Hospital, Chennai, India. The aim of the present study is to observe the
morphological changes in polycystic ovaries of patients. Fifty PCOS patients of age
between 18 and 35 years who satisfied the Rotterdam criteria were recruited as
samples for the study by the fixed method of sampling. According to their
immediate participation in the study, they were either allocated to the intervention
group (n=25) or in the wait listed control group (1r=25). The study revealed Y&N
lifestyle could be the first-line interventions for PCOS. Small changes in lifestyle in
accordance to Y&N are known to improve symptoms and psychological well-being
of PCOS patients.
13. A systematic review and metanalysis conducted to assess the effects of lifestyle
modification in polycystic ovary syndrome compared to metformin only or
metformin addiction. I3 publications were finally included in the meta-analysis,
which were published between 2000 and 2018 and included four studies from
Europe, four studies from North America, two studies from South America, two
studies from the Middle East, and one study from Africa. These studies were divided
based on the comparisons made in them; six studies compared LSM with
metformin alone, eight studies compared LSM +metformin with LSM, and one study
was included in both. It concluded that based on this systematic review, the clinical
outcomes, such as improvement in the menstrual frequency and pregnancy
outcomes, were not significantly different between LSM and metformin. LSM tends
to have more benefits, except in terms of serum testosterone levels, than metformin
alone. The effectiveness of LSM + metformin is limited to phasing serum insulin
levels and menstrual cycles compared with LSM, and the addition of metformin to
LSM resulted in no significant benefits in lowering BM. Based on these results, we
suggest selecting the appropriate treatment carefully while considering the side
effects of metformin. If metformin is not indicated, LSM should be the primary
recommendation in women with PCOS before prescribing metformin'7.
14. A retrospective chart review of 368 patient records were assessed for inclusion
criteria yielding 163 patients with PCOS suffering from infertility. Demographic and
heath data were gathered for each patient to provide a baseline comparison
between the first two quarters of 2019 and the first two quarters of 2020. The results
of the study were mixed. Patients who lost weight did have a higher positive
pregnancy rate. However, as a byproduct of the study it was found that the Health
and Wellnes program is being underutilized and is using only a single modality for
treatment, The clinic is losing patients due to a lack of follow-up and there are
communications disconnect between the Health and Wellness program and the
clinic.
15. A review on siddha therapeutics for the management of pcos to assess various
Siddha formulations and available herbal-polyhedral practices for PCOS, which are
depicted in the literature as possessing potential values, are discussed with
scientific validations. Erythrina variegata L., Nigella sativa, Anthem graveolens, Vitex
negundo, Melia azadirach L., and Citrullus colocynths are some single herbs with
scientific evidence used for the treatment of PCOS. The study concluded that
Siddha medicinal plants and various Siddha formulations are effectively used for
the management of PCOS and its related complications. Besides, many other
plants and formulations that possess hypoglycemic activity (correds the insulin
resistance), hyperlipidemia activity (reduces obesity) and antiandrogenic activity
may also be used for the treatment of PCOS'9.

16. An experimental study was conducted to assess the effectiveness of aerobic

exercise and Lifestyle intervention among young women with polycystic ovary
syndrome. 30 samples with PCOS of age group 18-25 years which were further
distributed into two groups each with 15 samples were selected using based on
Rotterdam criteria 2003 and by simple random sampling technique. The group A
subjects were intervened witha45 min of brisk jogging on treadmill(aerobic exercise)
and group B performed active stretching exercises each for 20 seconds for I2 weeks.
The results showed group A was more effective than group B. The study concluded
that 12 weeks of aerobic exercise and stretching exercises with lifestyle
management had improvement on hormonal profile and quality of life improvement
in samples with PCOS. But aerobic exercises were more superior to stretching
exercise on hormonal profiles and quality of life improvement among young women
with PCOS.
17. A study conducted on effects of herbal teas on management of polycystic ovary
syndrome. The research databases included ISI, PubMed, Google Scholar, Scopus,
Science direct, Cochrane Library etc were used to search clinical trials and used key
 terms like herbal therapy and herbal medicine. Various studies were collected to
estimate the effects of herbal medicine on PCOS. The study revealed the positive
effect of various types of herbal teas on PCOS in different trials1.
18. A study was conducted to estimate the role of medicinal herbs in the treatment of
insulin resistance in patients with polycystic ovarian syndrome. All the related
articles were collected from various databases, including Web of Science, PubMed,
and Science Direct, from 1990 to 2019. 38 articles were finally included from 361
studies. The results indicate that some medicinal herbs can affect lipid profiles,
insulin resistance, blood glucose, hormones, and ovarian tissue. The study
concluded that natural Substances such as aloe vera, cinnamon, green tea,
fenugreek, and Silymarine can be used as a new supportive care for PCOS?.
19. A systematic review and metanalysis conducted of randomized control trials to
identify the effect of metformin in polycystic ovary syndrome in overweight women.
The data was collected from PubMed, Cochrane Library, Embase, CNKI, VIP, and
Wanfang databases. The results estimated that in all studies, overweight women
with polycystic ovary syndrome treated with metformin significantly improved
endocrine and metabolic indicators. The study concluded metformin appears to be
an effective intervention for overweight women with PCOS.
20. A prospective cross-sectional study conducted in Singapore on sleep duration,
exercise, shift work, and polycystic ovarian syndrome-related outcomes in a healthy
population. 231 women of 21-45 years, including health care workers, were selected
who participated in an annual health screen in the hospital and healthy volunteers
from the university community and healthy referral cases from the NUH women's
clinic. The study concluded that women with insufficient sleep are at increased risk
of menstrual disturbances and insulin resistance but do not have the
hyperandrogenism and polycystic ovarian morphology typical of PCOS.
21. A case-control study conducted to examine the healthy eating index in women with
polycystic ovary syndrome in Bagiyatalah Hospital Clinics, Tehman, Iran, 297
women aged 20-40 year were selected as samples and grouped into two groups as
case group (n=99) of PCOS women and a control group (n=198) of age- and body
mass index (BMI)-matched controls. A validated 168-item semi-quantitative food
frequency questionnaire was used to collect dietary data, and standard
anthropometric measurements (height, weight, and waist circumference) were also
taken. Unconditional logistic regression was used to analyze the relationship
between the PCOS and the HEL. The results revealed that the mean age and body
mass index of case and control groups were 29±5.5 vs. 29.5±6 years and 26.6±4.8
vs. 26±4.2 kg/m², and the mean HEL scores for the case and control groups were
found to be 61 and 65, respectively. In conclusion, the findings of the current study
 indicate that high compliance with the HEI-2010 core might be associated with
lower risk of PCOS in women. These findings could be significant, given the
increased attention to nutritional therapy in these patients.
22. A systematic review of published literature was conducted using EBSCO host and
Ovid Medline. The review adheres to the Preferred Reporting Items for Systematic
Review and Meta-Analyses (PRISMA) guidelines as per our PROSPERO protocol
(CRD42018088367). Randomized controlled trials, non-randomized controlled
trials, and uncontrolled trials that evaluated an exercise intervention of at least
moderate intensity in women with PCOS were included. Meta-analyses were
performed using general linear mixed modelling and Bayesian inferences about
effect magnitudes. Thirty-three articles were identified for systematic review of
which 19 were meta-analysed. Intervention duration ranged from 6 to 26 weeks. A
total number of 77 women were included in the meta-analysis. The meta-analysis
found that improvements in health outcomes are more dependent on exercise
intensity than dose. Results rom the analysis support the use of exercise and
suggest that vigorous intensity exercise may have the greatest impact on
cardiorespiratory fines, body composition, and insulin resistance, The results
indicate that a minimum of 120 min of vigorous intensity per week is needed to
provide favorable health outcomes for women with PCOS.
23. A comprehensive systematic search was conducted in Embase, MEDLINE/PubMed,
Google Scholar, and SCOPUS to identify studies investigating n-3 fatty acids as a
preventative or therapeutic agent for the attenuation of PCOS complications. N-3
PUFAs are a promising agent in relieving complications associated with PCOS.
There are multiple mechanisms by which n-3 PUFAs may exert their beneficial
effects on PCOS women, including anti-obesity, glycemic and hormonal
homeostasis, anti-inflammatory, regulation of adipocyte production, and
enhancement of endothelial function [7].
24. A review analyzes studies identified on PubMed in three categories:1) polycystic
ovary syndrome, 2) the comorbid conditions associated with PCOS (depression,
diabetes, obesity, metabolic syndrome, luteinizing hormone levels, gonadotropin-
releasing hormone levels), and 3) the effects of mindfulness meditation for
depression, diabetes, obesity, metabolic syndrome, luteinizing hormone levels, and
gonadotropin-releasing hormone levels. and the studies published between January
1988 and May 2017, the study revealed that there are potential benefits of
mindfulness meditation in the individual symptoms; there seems to be a potential
benefit to using mindfulness meditation to treat the symptoms of PCOS and help
patients with this condition have a better quality of life.
25. A randomized, single-blinded, passive-control, parallel-group trial was conducted
on mindfulness meditation as a treatment for symptoms of polycystic ovary
syndrome. 57 samples with a mean age of 22.50 ±2.35 years and diagnosed with
PCOS were randomly divided into Pilates and control groups. The Plates group
received online Pilates exercise for 60 minutes/session, three times/week for eight
weeks, along with a lifestyle modification pamphlet. The control group performed
aerobic exercises for the same duration based on the recommendations received in
the pamphlet. Pre and post assessment for body composition, using bioelectrical
impedance and waist circumference, and for quality of life by polycystic ovary
syndrome questionnaire was done by a binded assessor. Intra-group analysis was
done using matched t-test and Wilcoxon Signed rank [Link]-group analysis was
done using unmatched t-test and Mann Whitney-U test with alpha set at ps0.05 at
95% CI. The results estimated that pilates is effective in reducing total body weight,
waist circumference, body fat percent, BMT, visceral fat and all domains of quality of
life (ps0. 05) but does not offer any additional benefits for improvement of muscle
mass (p=0.65) in women with PCOS. The study concluded that pilates exercise is an
effective method in improving body composition and quality of life in women with
PCOS.