A pilot study to analyze the quality of sleep by pittsburgh sleep quality index in patients with polycystic ovary syndrome

Sunil Chouhan; Ajay Haldar; Ruchi Singh; Ragni Shrivastava

doi:10.4103/jascp.jascp_7_20

ORIGINAL ARTICLE

Year : 2021 | Volume : 2 | Issue : 1 | Page : 22-25

A pilot study to analyze the quality of sleep by pittsburgh sleep quality index in patients with polycystic ovary syndrome

Sunil Chouhan¹, Ajay Haldar², Ruchi Singh¹, Ragni Shrivastava¹
¹ Department of Physiology, All India institute of Medical Sciences, Bhopal, Madhya Pradesh, India
² Department of Obstetrics and Gynaecology, All India institute of Medical Sciences, Bhopal, Madhya Pradesh, India

Date of Submission	24-Nov-2020
Date of Decision	13-Mar-2021
Date of Acceptance	29-Jan-2021
Date of Web Publication	23-Mar-2021

Correspondence Address:
Dr. Sunil Chouhan
Department of Physiology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jascp.jascp_7_20

Abstract

Background: Various studies have shown that polycystic ovary syndrome (PCOS) patients have sleeping problems and disturbances associated with depression, anxiety, stress, drowsy driving, and other clinical symptoms. This study was taken to investigate the sleep status in POCS women according to the Rotterdam criteria. Aim: This was a pilot study to analyze the quality of sleep by Pittsburgh Sleep Quality Index (PSQI) in patients with poly ovary cystic disease in Bhopal. Materials and Methods: Sixty-two PCOS patients (mean age-24.54 ± 2.63 years) and 31 healthy controls (mean age: 23.20 ± 3.9 years) were recruited from AIIMS, Bhopal, who were evaluated for specific sleep quality by means of PSQI questionnaires. A PSQI global score of ≥5 confirmed the presence of poor quality of sleep. Results: The POCS patients have a global score of 7.97 ± 3.61 than the non-POCS control group 5.42 ± 2.73, thereby indicating that POCS patients have poor sleep quality. Among the seven components, “sleep latency” has a maximum mean score of 1.85 ± 0.99 (control = 1.23 ± 0.85) and a minimum mean score of 0.32 ± 0.82 (control = 0.21 ± 0.75) was attributed to the “use of sleeping Medicine” component. The PSQI mean scores of POCS patients were 1.44 ± 1.44, 1.39 ± 0.61, and 0.89 ± 1.10 for “Subjective sleep quality,” “sleep disturbance,” and “sleep duration,” respectively, and the results were statistically significantly (P < 0.05) when compared to other components and control. Conclusion: This study on the basis of substantiation data found evidence that PCOS women have a relatively poor quality of sleep when compared with the normal control group.

Keywords: Polycystic ovary syndrome, Pittsburgh Sleep Quality Index, sleep quality

How to cite this article:
Chouhan S, Haldar A, Singh R, Shrivastava R. A pilot study to analyze the quality of sleep by pittsburgh sleep quality index in patients with polycystic ovary syndrome. J Appl Sci Clin Pract 2021;2:22-5

How to cite this URL:
Chouhan S, Haldar A, Singh R, Shrivastava R. A pilot study to analyze the quality of sleep by pittsburgh sleep quality index in patients with polycystic ovary syndrome. J Appl Sci Clin Pract [serial online] 2021 [cited 2023 Mar 29];2:22-5. Available from: http://www.jascp.org/text.asp?2021/2/1/22/311764

Introduction

Polycystic ovarian syndrome (PCOS) is often associated with sleeping disturbances.^[1],[2],[3] Some of the common sleep disturbance conditions which are prevalent in the common people are sleep apneas, insomnia, delayed sleep phase, affective disorder, daytime sleepiness, sleepwalking, nightmares, and restless leg movement.^[4],[5] It is a multifaceted disorder, found approximately among 5%–10% of females of their reproductive age.^[6] In one of the studies, it was found that women aged around in their 30s with PCOS have double sleep disturbance as compared to their normal counterparts, but the reason for so was not clear.^[7] There are three international bodies available which have established diagnostic criteria for PCOS: National Institutes of Health/National Institute of Child Health and Human Disease;^[8] the European Society for Human Reproduction and Embryology/American Society for Reproductive Medicine or the “Rotterdam Criteria;”^[9] and the Androgen Excess and PCOS Society.^[10] The Rotterdam criteria are widely accepted for diagnosis and for reference guidelines across the world and in this study, we have applied Rotterdam criteria for nonsymptomatic POCS patient's selection. According to these criteria, presence of any two (1. oligo/anovulation, 2. hyperandrogenism, and 3. polycystic ovaries on ultrasound) is necessary for the diagnosis of poly ovary cystic disease (POCD).^[11],[12] The PCOS has affected 116 million females (3.4%) around the world as per the survey by the World Health Organization in 2012.^[13] In India, the prevalence rate ranges from 2.2% to 26%.^[14] PCOS patients often report of sleep disturbances in a study conducted on clinic-based samples of clinic-based samples of POCS patients.^[15] In young adults, 7–9 h of sleep which is an essential part of life is necessary for a person's good health life.^[16] Inadequate amount of sleep can lead to petulance, fatigability, altered sleep duration, delay of sleep onset, and difficulty in maintaining sleep decline of cognitive and psychomotor function which required behavioral, cognitive, and pharmacologic interventions.^{[17],[18],[19],[20]} Even blood pressure and C-reactive protein are elevated, which is being associated with coronary artery disease.^[21],[22] PCOS which is a lifelong complex metabolic condition disorder associated with psychological and metabolic health is associated with sleep disturbances and disorders.^[23] They had a greater incidence of OSA, onset sleep disorders, and sleep disturbance^{[7],[24],[25]} and significantly higher sleep latency.^[26] PCOS has a higher risk of mood, anxiety disorders, higher depression^[27] scores, and higher risk of depression independent of body mass index (BMI).^[28],[29] The most psychologic patterns in PCOS patients are chronic anxiety and depression.^[30] Various research has shown that POCS patients have abnormal sleep when compared to normal counterpart, thus affecting the quality of sleep.^{[15],[31],[32]} The aim of this present study is to evaluate the quality of sleep in women diagnosed with PCOS in comparison to the control group with the help of Pittsburgh Sleep Quality Index (PSQI).

Materials and Methods

In this cross-sectional study, the female patient in the age group of 18–40 was engaged from the department of obstetrics and gynecology, AIIMS, Bhopal, from January 2015 to November 2017. This voluntary questioner PSQI was asking to fill by women who were diagnosed based on the Rotterdam Criteria. Prior to the commencement of the study, written consent was obtained from all the participants involved in this study. The demographic data such as age, gender, height, and weight were taken from POCS patients. The POCD patients were recruited and a matching control group was taken to ensure comparison with respect to similar in mean BMI, mean age, mean height, mean weight, and race distribution without having POCD. The inclusion criteria were (1) women diagnosed with POCS between 18–40 year old without signs of the disease according to Rotterdam criteria and (2) should be able to understand and write either in Hindi or English.

Assessment of sleep by Pittsburgh Sleep Quality Index

The PSQI is an instrument developed by Buysseand which is used to analyze the patient's self-reported sleep quality and disturbances during the past 1 month.^[26] The PSQI translation in Hindi and English and was obtained from the author (version of 12 sep 09-Mapi-ID4211/PSQI_AU1.2_hin-IN. doc) with the permission to use this scale. This PSQI questionnaire consists of 19 questionnaires/items and consists of 7 component scores, each of which has a range of 0–3 points, 0 indicating no difficulty, whereas 0 indicates severe difficulty. The seven components are sleep duration, disturbance, latency, daytime dysfunction, efficiency, quality, and medication. All the seven-component score was added to yield one global score which ranges from 0 to 21 points. A score ≤5 indicates good sleep, and on the other hand, a score >5 indicates poor seep. In each domain, the score ranges from 0 to 3. These numerical scores give a clinician a whole synopsis of patient quality of sleep, thus helping to arrive at a conclusion for the management of the patients.

Ethical considerations

The present study was conducted with the approval of the Ethics Committee AIIMS, Bhopal.

Statistical evaluation

The participants were asked to fill PSQI questionnaire following informed written consent from them. The statistical analysis was done using IBM SPSS Software Version 21 interactive, or batched, statistical analysis (2012). Descriptive study for variables such as frequencies, ranges, means, medians, and SD for the participants and PSQI and inferential statistics was done. In the PSQI subgroup components, independent sample t-test was used for the analysis. Statistical significance was set at P < 0.05.

Results

The data were summarized for measures of central tendency and dispersion. Every individual question was treated on an ordinal scale and hence was summarized by median and IQR values (interquartile range). The composite score for a single component was treated on the internal scale and was summarized by the mean and standard deviation.

Although the seven components of PSQI showed a higher value among the POCS group, three subscales could qualify as significant, namely “Subjective sleep quality,” “sleep disturbance,” and “sleep duration.” The components of subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medicine, and daytime dysfunction scores were higher in POCS patients as compared to the control group [Table 1] and it has been shown in the form of bar diagram in [Figure 1]. The global score shows the mean difference of 2.54 (1.087–4.009, 95% confidence interval [CI]). This difference was found significance at 95% CI (t = 3.46, P = 0.01, df = 91) [Table 1]. The global scores for the POCS patients and control were 7.97 ± 3.61 and 5.42 ± 2.73, respectively [Table 2]. The component of subjective sleep quality, sleep latency, and sleep disturbance was significantly higher in patients with POCS as compared to healthy controls (P < 0.05) [Table 1].

Figure 1: Mean POCS patients and control

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Table 1: PSQI components of POCS patients and control

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Table 2: Global score

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Discussion

In this study, poor sleep quality has been analyzed in POCD women using PSQI questionnaire study. An association between quality of sleep and PCOS patients according to the Pittsburgh Sleep Quality Index was analyzed. We found that “Subjective sleep quality,” “sleep disturbance,” and “sleep duration” were statistically significant (P < 0.05) when compared to other components of PSQI and control women. The PSQI score of 7.97 (control = 5.42) [Table 1] is (>5) clearly indicated that sleeping quality has deteriorated in POCS patients. The use of medicine for sleeping was higher in POCS patients as compared to normal.

In a research study done on PCOS patients, it was found that POCS patients have reduced sleep (sleep duration) than women without PCOS,^[33] this finding is similar to our present study in which sleep duration (Mean = 0.89/control = 0.32) has decreased significantly. The POCS females are affected with increased sleep disturbance as compared to normal control females in this present study which reconfirmed the fact found in other research studies.^[31] Among the various symptoms in POCS patients, anxiety may be one of the factors for poor sleep quality. In our study, “Daytime Dysfunction” and “Habitual sleep efficiency” scores were not found significantly associated with the sleep quality. The viewpoint of ankylosing spondylitis was not seen in the present POCS patients and research studies state that there is a reduction of subjective sleep quality, habitual sleep efficiency, and total PSQI^[34] scores in POCS patients; hence, lack of information on these aspects may be one of the bias factors involved in this study. The component of “sleep latency” had a maximum mean score of 1.85 ± 0.99 (control = 1.23 ± 0.85) which reaffirm the result obtain by Moran et al. by questionnaire study that POCS patients are associated with increasing incidence with falling asleep. In addition, sleep disturbances' prevalence was as high as twice the value found among POCS women as compared to normal women.^[33] The daytime sleepiness component was high as compared to control, which has been reported in the available literature.^[35]

The examination of the association between the PSQI and POCS suggests that poor sleep quality was detected in patients with POCS as compared to control. This PSQI can be a good noninvasive screening tool for assessing the quality of sleep in POCS patients, but it cannot replace diagnosis and management of a sleep expert. Moreover, it should not be used while evaluating sleep quality in psychiatric patients, alcoholic, and drug abuse patients.

Conclusion

The results of this study indicate poor sleep quality in POCD women using the PSQI questionnaire. Moreover, PSQI different component scores may provide useful information about sleep quality while screening evaluation of sleep is made in POCS patients.

Limitation of the study

Since this was the pilot study, the study population was very small. We believe that the more future validation studies with taking a large number of sample size on the Indian population can be analyzed to develop strategies and management of sleep quality for POCS patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Tasali E, Van Cauter E, Hoffman L, Ehrmann DA. Impact of obstructive sleep apnea on insulin resistance and glucose tolerance in women with polycystic ovary syndrome. The Journal of Clinical Endocrinology & Metabolism. 2008;93:3878-84.
2.	Nitsche K, Ehrmann DA. Obstructive sleep apnea and metabolic dysfunction in polycystic ovary syndrome. Best Pract Res Clin Endocrinol Metab 2010;24:717-30.
3.	Sundaram SS, Halbower AC. What do Ovaries have to do with Sleeping?. The Journal of pediatrics 2011;159:526-7.
4.	Gaultney JF. The prevalence of sleep disorders in college students: Impact on academic performance. J Am Coll Health 2010;59:91-7.
5.	Sweileh WM, Ali IA, Sawalha AF, Abu-Taha AS, Zyoud SH, Al-Jabi SW, et al. Sleep habits and sleep problems among Palestinian students. Child Adolesc Psychiatry Ment Health 2011;5:25.
6.	Allahbadia GN, Merchant R. Polycystic ovary syndrome in the Indian subcontinent. Semin Reprod Med 2008;26:22-34.
7.	Moran LJ, March WA, Whitrow MJ, Giles LC, Davies MJ, Moore VM, et al. Sleep disturbances in a community-based sample of women with polycystic ovary syndrome. Hum Reprod 2015;30:466-72.
8.	Zawadski JK, Dunaif A. Diagnostic Criteria for Polycystic Ovary Syndrome: Towards a Rational Approach. In: Dunaif A, Givens JR, Haseltine F, Eds., Polycystic Ovary Syndrome, Blackwell Scientific, Boston, 1992:377-84.
9.	Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril 2004;81:19-25.
10.	Azziz R, Carmina E, Dewailly D, Diamanti-Kandarakis E, Escobar-Morreale HF, Futterweit W, et al. Positions statement: Criteria for defining polycystic ovary syndrome as a predominantly hyperandrogenic syndrome: An Androgen Excess Society guideline. J Clin Endocrinol Metab 2006;91:4237-45.
11.	Wang, R, Mol BW. The Rotterdam criteria for polycystic ovary syndrome: Evidence-based criteria? Hum Reprod 2017;32:261-4.
12.	Franks S. Controversy in clinical endocrinology: Diagnosis of polycystic ovarian syndrome: In defense of the Rotterdam criteria. J Clin Endocrinol Metab 2006;91:786-9.
13.	Kabel AM. Polycystic ovarian syndrome: Insights into pathogenesis, diagnosis, prognosis, pharmacological and non-pharmacological treatment. J Pharma Reports 2016;1:2.
14.	Nidhi R, Padmalatha V, Nagarathna R, Amritanshu R. Prevalence of polycystic ovarian syndrome in Indian adolescents. J Pediatr Adolesc Gynecol 2011;24:223-7.
15.	Shreeve N, Cagampang F, Sadek K, Tolhurst M, Houldey A, Hill CM, et al. Poor sleep in PCOS; is melatonin the culprit? Hum Reprod 2013;28:1348-53.
16.	Hirshkowitz M, Whiton K, Albert SM, Alessi C, Bruni O, DonCarlos LY, et al. National sleep foundation's sleep time duration recommendations: Methodology and results summary. Sleep Health 2015;1:40-3.
17.	Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Management of chronic insomnia disorder in adults: A clinical practice guideline from the American College of Physicians. Ann Intern Med 2016;165:125-33.
18.	Brassington GS, King AC, Bliwise DL. Sleep problems as a risk factor for falls in a sample of community-dwelling adults aged 64–99 years. J Am Geriatr Soc 2000;48:1234-40.
19.	Manabe K, Matsui T, Yamaya M, Sato-Nakagawa T, Okamura N, Arai H, et al. Sleep patterns and mortality among elderly patients in a geriatric hospital. Gerontology 2000;46:318-22.
20.	Ogawa Y, Kanbayashi T, Saito Y, Takahashi Y, Kitajima T, Takahashi K, et al. Total sleep deprivation elevates blood pressure through arterial baroreflex resetting: A study with microneurographic technique. Sleep 2003;26:986-9.
21.	Meier-Ewert HK, Ridker PM, Rifai N, Regan MM, Price NJ, Dinges DF, et al. Effect of sleep loss on C-reactive protein, an inflammatory marker of cardiovascular risk. J Am Coll Cardiol 2004;43:678-83.
22.	El Hayek S, Bitar L, Hamdar LH, Mirza FG, Daoud G. Poly cystic ovarian syndrome: An updated overview. Front Physiol 2016;7:124.
23.	Jenkins CD, Stanton BA, Niemcryk SJ, Rose RM. A scale for the estimation of sleep problems in clinical research. J Clin Epidemiol 1988;41:313-21.
24.	Lin TY, Lin PY, Su TS, Li CT, Lin WC, Chang WH, et al. Risk of developing obstructive sleep apnea among women with polycystic ovarian syndrome: A nationwide longitudinal follow-up study. Sleep Med 2017;36:165-9.
25.	Hung JH, Hu LY, Tsai SJ, Yang AC, Huang MW, Chen PM, et al. Risk of psychiatric disorders following polycystic ovary syndrome: A nationwide population-based cohort study. PloS One 2014;9:e97041.
26.	Tasali E, Van Cauter E, Ehrmann DA. Relationships between sleep disordered breathing and glucose metabolism in polycystic ovary syndrome. J Clin Endocrinol Metab 2006;91:36-42.
27.	Barry JA, Kuczmierczyk AR, Hardiman PJ. Anxiety and depression in polycystic ovary syndrome: A systematic review and meta-analysis. Hum Reprod 2011;26:2442-51.
28.	Dokras AJ. Mood and anxiety disorders in women with PCOS. Steriods 2012;77:338-41.
29.	Dokras A, Clifton S, Futterweit W, Wild R. Increased prevalence of anxiety symptoms in women with polycystic ovary syndrome: Systematic review and meta-analysis. Fertil Steril 2012;97:225-30.e2.
30.	Sayyah-Melli M, Alizadeh M, Pourafkary N, Ouladsahebmadarek E, Jafari-Shobeiri M, Abbassi J, et al. Psychosocial factors associated with polycystic ovary syndrome: A case control study. J Caring Sci 2015;4:225-31.
31.	Vgontzas AN, Legro RS, Bixler EO, Grayev A, Kales A, Chrousos GP. Polycystic ovary syndrome is associated with obstructive sleep apnea and daytime sleepiness: Role of insulin resistance. J Clin Endocrinol Metab 2001;86:517-20.
32.	Zanisi M, Messi E. Sex steroids and the control of LHRH secretion. J Steroid Biochem Mol Biol 1991;40:155-63.
33.	Fernandez RC, Moore VM, Van Ryswyk EM, Varcoe TJ, Rodgers RJ, March WA, et al. Sleep disturbances in women with polycystic ovary syndrome: Prevalence, pathophysiology, impact and management strategies. Nat Sci Sleep 2018;10:45-64.
34.	Da Costa D, Zummer M, Fitzcharles MA. Determinants of sleep problems in patients with spondyloarthropathy. Musculoskelet Care 2009;7:143-61.
35.	Nandalike K, Strauss T, Agarwal C, Coupey SM, Sin S, Rajpathak S, et al. Screening for sleep-disordered breathing and excessive daytime sleepiness in adolescent girls with polycystic ovarian syndrome. J Pediatr 2011;159:591-6.