Knowledge, Attitude, and Practice of Lifestyle Modifications Among Saudi Women Diagnosed With Polycystic Ovary Syndrome (PCOS)

Background Polycystic ovary syndrome (PCOS) is a common endocrine disorder in women, often associated with metabolic issues like obesity and insulin resistance. Lifestyle changes, including weight loss, healthy eating, and regular exercise, are recommended for PCOS management. Studies have explored women's perspectives on these changes, revealing misconceptions and adherence challenges. Recognizing the importance of individualized interventions, particularly addressing knowledge gaps, is vital for improving the quality of life for women with PCOS, especially in cultural contexts like Saudi Arabia. Methodology This was a cross-sectional study conducted in Saudi Arabia from May to August 2023 including PCOS patients. Data was collected through questionnaires and analyzed using IBM SPSS 29 (IBM Corp. Released 2020. IBM SPSS Statistics for Windows, Version 27.0. Armonk, NY: IBM Corp). This study was conducted in accordance with the ethical guidelines and principles outlined by the Scientific Research Ethics Committee of Taif University (no.44-359). All participants provided informed consent, and the study protocols, including data collection, analysis, and publication, adhered to the relevant ethical standards. Results Our study included a majority aged 18-29 (27.4%), married individuals (55.6%) and those with a Bachelor's degree (72%). About 46.9% were medically diagnosed with PCOS. A notable proportion (70.2%) reported no family history of PCOS. Doctors were the primary information source (40.7%). Knowledge about PCOS was generally high, with correct recognition of various PCOS characteristics and treatment options. Attitudes were positive, especially among medically diagnosed individuals, and 91% believed weight reduction could improve PCOS symptoms. Lifestyle modification knowledge, attitude, and practices showed significant associations with demographic factors like age, place of residence, education, marital status, working in healthcare sectors, and PCOS diagnosis status. Conclusions Knowledge about PCOS is generally high among women with positive attitudes toward its management through lifestyle modifications. Women generally show positive practices of lifestyle modifications in PCOS, and they are associated with sociodemographic features.


Introduction
Polycystic ovarian syndrome (PCOS) is a condition caused by hormonal imbalance in women of reproductive age [1].The symptoms include ovulating problems, hyperandrogenism, and ovarian cysts [2].PCOS is associated with metabolic problems such as obesity, insulin resistance, and hypercholesterolemia, which might lead to severe complications like type two diabetes and cardiovascular diseases [3].However, a healthy lifestyle, such as a balanced diet, regular exercise, and weight loss, has been shown to improve metabolic health in women with PCOS and prevent further complications [4,5].Based on the counsel of experts such as the American Association of Clinical Endocrinologists, the American College of Endocrinology, and the Androgen Excess and PCOS Society Disease State Clinical Review [6], the initial treatment of PCOS should begin with lifestyle modification.They also stated that women with PCOS are recommended to lose 5%-10% of their body weight, follow a healthy diet, and exercise regularly [7].These changes showed to benefit PCOS-affected women in terms of their health and infertility outcomes.Various researchers have studied the knowledge, attitudes, and practices of women with PCOS regarding lifestyle changes.For example, in Taif, Saudi Arabia, Albezrah and Arein (2019) studied women's perspectives on weight loss, which has revealed misconceptions about the condition and a lack of consistency in adopting healthy dietary and exercise habits [8].Furthermore, a study conducted in Australia by Ranasinha et al. (2015) found that Australian women with PCOS have a high prevalence of metabolic risk factors, which healthy lifestyle choices can reduce [9].Moreover, a study by Cowan et al. (2023) pointed out that lifestyle adjustment may lead to improved metabolic disorders like insulin resistance, glucose tolerance, and lipid profiles among women with PCOS [5].These findings emphasize the significance of individualized interventions considering cultural, social, and psychological factors when managing PCOS.To sum it up, the effectiveness of lifestyle modification in managing PCOS in women has been observed.In our research, we will measure the extent of the gaps in knowledge of Saudi women with polycystic ovary syndrome to make it easier for doctors to address these misconceptions and improve the quality of life of the patients.

Study design and subjects
The study employed a cross-sectional design.Data was collected by a randomized, self-administered questionnaire, which was sent to the respondents electronically via e-mail from May 25, 2023, to August 25, 2023.The research was carried out in a questionnaire-based setting and comprised four sections: A) Sociodemographic data will be collected such as age, residency, education level, nationality, place of residence, and marital status.B) Knowledge of participants about polycystic ovarian syndrome such as did you heard about PCOS before, source of knowledge, what are the problems of PCOS, and methods of treatment.C) Attitude and practice of the PCOS patients about weight reduction and/or lifestyle modification such as weight reduction is an effective treatment if yes how does weight reduction improve your condition or if no why not effective?D) Daily practices of the PCOS patients such as low low-fat foods, eating smaller portions at dinner, and exercising for 30 minutes.To establish the sample size, the Raosoft sample size calculator (Raosoft Inc., Seattle, WA, USA, raosoft.com) was utilized, resulting in a requirement for 385 PCOS (polycystic ovary syndrome) patients to achieve a 95% confidence interval with a 5% margin of error.The study included all registered PCOS patients residing in Saudi Arabia, excluding individuals who did not suffer from PCOS.

Data analysis
Data was collected using an Excel (Microsoft Corporation, 2018) sheet for coding, and subsequent analysis was conducted with IBM SPSS version 27 (IBM Corp. Released 2020.IBM SPSS Statistics for Windows, Version 27.0.Armonk, NY: IBM Corp).For continuous variables, measures of central tendency were computed, while frequencies and percentages were estimated for categorical variables.In the case of continuous variables, the comparison was performed using the Wilcoxon Mann-Whitney test, represented as mean ±.Categorical variables were analyzed using independent sample t-tests, analysis of variance, and the Chi-Square test of independence, with results expressed in absolute values and percentages.

Ethical considerations
This study was conducted in accordance with the ethical guidelines and principles outlined by the Scientific Research Ethics Committee of Taif University (no.44-359).All participants provided informed consent, and the study protocols, including data collection, analysis, and publication, adhered to the relevant ethical standards.

Frequency (N)
Percent (%)   Participants recognized various benefits of weight reduction in managing PCOS.A minority of participants believed it could lead to improvements in multiple aspects, including menstrual irregularities (N=27, 6.9%), psychological condition (N=28, 7.1%), and the possibility of getting pregnant (N=11, 2.7%).A significant portion (N=302, 79.5%) acknowledged that it could have an overall positive impact on PCOS (Figure 2).Practices include incorporating low-salt foods, eating fruits and vegetables, reducing refined sugar, consuming high-fiber foods, and exercising.Hormonal preparations are used to manage irregular periods, acne, and infertility.Some participants use herbal medications and topical creams.Laparoscopic ovarian drilling is less common (Table 3).The relationship between knowledge about PCOS and various demographic factors shows that the western region (N=134) is significantly associated with higher knowledge (p<0.001).Participants with monthly income >10,000 SAR (N=123) show significantly higher knowledge levels (p=0.038).Healthcare workers (N=64) and individuals diagnosed with PCOS (N=135) are also associated significantly with high knowledge levels (p=0.003,<0.001).The participants' age, educational level, marital status, nationality, and BMI do not significantly impact knowledge about PCOS.Interestingly, even those without a formal PCOS diagnosis exhibit variable knowledge levels (Table 4).

Discussion
PCOS, a common disorder in women, is linked to metabolic problems.Lifestyle changes are crucial for management, but women may have misconceptions and adherence issues.Our study shed light on the knowledge, attitudes, and practices of lifestyle modifications among Saudi women diagnosed with polycystic ovary syndrome (PCOS).
Most participants were young adults, in line with PCOS onset patterns.This aligns with previous findings that PCOS often affects women aged 18-44 years [2,10].Additionally, a substantial number were married, highlighting the need for early detection and management.In terms of education, 72% of participants had a Bachelor's degree, suggesting that higher education might not necessarily correlate with greater PCOS awareness.This finding contradicts some previous studies that found a positive association between education level and PCOS knowledge [11].It emphasizes the need for educational initiatives targeting all strata of society.Regarding nationality, the majority of participants were Saudi, reflecting the country's population.However, PCOS's impact can vary among ethnicities due to genetics and environment, necessitating further research [12].
Most participants primarily relied on healthcare professionals for PCOS information, aligning with their vital role in diagnosis and education.However, low use of social media and the internet indicates room for improved public awareness through these sources, potentially leading to earlier PCOS diagnosis and better management [13].
Most participants had a good level of knowledge about PCOS, including its symptoms and potential complications.This finding is in contrast with previous research that demonstrated a generally low level of PCOS knowledge among women diagnosed [14].It is reassuring that participants recognized the links between PCOS and diabetes, heart diseases, infertility, and mental health issues.Such awareness is vital for comprehensive PCOS management.
The positive attitudes toward PCOS were also notable.Participants recognized various treatment options, including hormonal therapy, anti-diabetic medications, symptomatic treatments, and surgery.Weight reduction was seen as a potential means to improve PCOS symptoms, reflecting the importance of lifestyle modifications in PCOS management.This aligns with previous studies emphasizing the role of lifestyle modifications in improving PCOS outcomes [15].
The majority of participants reported no family history of PCOS.This contradicts the known hereditary component of PCOS, which suggests that there might be underreporting or a lack of awareness within families about PCOS cases.Previous studies show that family history is an independent risk factor for PCOS [16].Educating families about the condition and its potential genetic link may lead to earlier detection of family members at risk.
The relationship between knowledge about PCOS and various demographic factors, such as age, educational level, marital status, nationality, and BMI, did not significantly impact PCOS knowledge.This finding contrasts with previous research indicating that education level could influence PCOS knowledge [17].However, participants with PCOS diagnosis exhibited significantly higher knowledge levels, suggesting that awareness campaigns should target both diagnosed and undiagnosed individuals.
Significant associations between attitude toward PCOS and age, region, healthcare worker, and diagnosis status were found.Medically diagnosed participants were more likely to have a positive attitude.This aligns with the concept that diagnosis and awareness of one's condition can lead to more positive attitudes and proactive management [18].While other demographic factors did not show significant associations with attitude, it is essential to recognize that a positive attitude is a crucial factor in motivating individuals to adhere to lifestyle modifications and treatment regimens [19].
Regarding the association between lifestyle modification practices related to PCOS and various participant characteristics, several significant associations were found, it is worth noting a trend where participants with a medical PCOS diagnosis were more likely to have positive lifestyle modification practices, and this trend is statistically significant [20].
Our study highlights the importance of inclusive educational initiatives to raise awareness about PCOS, particularly addressing the genetic aspect due to low reported family history.Healthcare providers must offer comprehensive information, emphasizing lifestyle modifications.Online resources and support groups can supplement these efforts, fostering a sense of community among PCOS individuals.
This study has limitations, including its relatively small sample size and potential selection bias.Future research could include a larger and more diverse sample to enhance generalizability.Additionally, qualitative research may provide deeper insights into the experiences and challenges faced by Saudi women with PCOS.

Conclusions
Healthcare professionals play a pivotal role in providing information about PCOS, reflecting the importance of early diagnosis and patient education.The positive attitudes exhibited by the participants, coupled with their recognition of various treatment options, including lifestyle modifications, are promising indicators of comprehensive PCOS management.Weight reduction, in particular, was recognized as a potential means to alleviate PCOS symptoms, reaffirming the significance of lifestyle modifications in the management of this condition.Future research with larger and more diverse samples is needed, as well as qualitative research to delve deeper into the experiences and challenges faced by Saudi women with PCOS.

FIGURE 2 :
FIGURE 2: Benefits of weight reduction in PCOS PCOS: polycystic ovary syndrome.

TABLE 1 : Sociodemographic of participants
PCOS: polycystic ovary syndrome, Hx: history.Regarding the sources of information about PCOS, the most common source was doctors, with 40.7% (N=155) of participants obtaining information from doctors and other advanced practice providers.A smaller percentage relied on social media (N=107, 28.1%), internet (N=72, 18.9%), and other sources (N=43, 11.3%)

TABLE 3 : Assessment of practice regarding lifestyle modifications in PCOS (n=379)
PCOS: polycystic ovary syndrome.

TABLE 4 : Association of knowledge about PCOS with demographic data
PCOS: polycystic ovary syndrome.

TABLE 5 : Association of attitude toward PCOS with demographic data
PCOS: polycystic ovary syndrome.

TABLE 6 : Association of practice regarding lifestyle modifications in PCOS with different features
PCOS: polycystic ovary syndrome.