Referral Bias in Defining the Phenotype and Prevalence of Obesity in Polycystic Ovary Syndrome
Open accessAbstract
BACKGROUND: The described phenotype of the polycystic ovary syndrome (PCOS) has been primarily based on findings in a referred (self or otherwise) population. It is possible that the phenotype of PCOS would be different if the disorder were to be detected and studied in its natural (unbiased) state. OBJECTIVE: Our objective was to compare the phenotype of PCOS detected in an unselected population with that identified in a referral population. PARTICIPANTS: Participants included 292 PCOS patients identified at a tertiary care outpatient facility (referral PCOS) and 64 PCOS women (unselected PCOS) identified through the screening of a population of 668 seeking a pre-employment physical. Among the women undergoing a pre-employment physical, 563 did not demonstrate features of the disorder (unselected controls). All PCOS subjects met the National Institutes of Health 1990 criteria for the disorder. MAIN OUTCOME MEASURES: We estimated prevalence of obesity and severity of disease burden. RESULTS: Referral PCOS subjects had greater mean body mass index and hirsutism score and higher degrees of hyperandrogenemia, were more likely to be non-Hispanic White (83.90%), and demonstrated a more severe PCOS subphenotype than unselected PCOS or unselected controls. The prevalence of obesity and severe obesity in referral PCOS was 2.3 and 2.5 times greater than estimates of the same in unselected PCOS and 2.2 and 3.8 times greater than estimates in unselected controls, respectively. Alternatively, unselected PCOS subjects had a prevalence of obesity and severe obesity and a mean body mass index similar to those of the general population from which they were derived. CONCLUSION: The phenotype of PCOS, including the racial/ethnic mix, severity of presentation, and rate of obesity, is affected significantly by whether the PCOS subject arises from a referral population or through unselected screening, likely reflecting the degree of patient concern and awareness and access to healthcare.
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When comparing the prevalence of obesity in individuals with PCOS in medically unbiased or unreferred populations, the BMI distribution between individuals with and without PCOS appears to be more similar.
“When comparing the prevalence of obesity in individuals with PCOS in medically unbiased or unreferred populations, the BMI distribution between individuals with and without PCOS appears to be more similar [4,48,49].”
From Moving beyond Weight: A Narrative Review of the Dietary and Lifestyle Management for Reducing Cardiometabolic Risk in Polycystic Ovary Syndrome (PCOS) (2023) · cites this paper as [48]
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Characterization of polycystic ovary syndrome among Flo app users around the world
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The association of the lipidomic profile with features of polycystic ovary syndrome
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Dietary carbohydrate composition is associated with polycystic ovary syndrome: a case–control study
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Self-citationReferral bias in female functional hyperandrogenism and polycystic ovary syndrome
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The impact of ageing and menopause in women with polycystic ovary syndrome
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The pressing need for standardization in epidemiologic studies of PCOS across the globe
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Minimal difference in phenotype between adolescents and young adults with polycystic ovary syndrome
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Self-citationPolycystic ovary syndrome: Criteria, phenotypes, race and ethnicity
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Breastfeeding and obesity in PCOS
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Diagnosis, Management, and Associated Comorbidities of Polycystic Ovary Syndrome: A Narrative Review
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Polycystic ovary syndrome and pregnancy – From a clinical perspective
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How polycystic ovary syndrome came into its own
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Self-citationCurrent treatment for polycystic ovary syndrome: focus on adolescence
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Polycystic Ovary Syndrome: Is Obesity a Symptom?
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Suspected ontogeny of a recently described hypo-androgenic PCOS-like phenotype with advancing age
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An Evolutionary Model for the Ancient Origins of Polycystic Ovary Syndrome
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Metabolomic Biomarkers in Polycystic Ovary Syndrome: A Review of the Evidence
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Associations of Childhood Adiposity and Cardiometabolic Biomarkers With Adolescent PCOS
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A Comprehensive Approach in Diagnosing the Polycystic Ovary Syndrome
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Basal metabolic rate in women with PCOS compared to eumenorrheic controls
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Self-citationFemale pattern hair loss and polycystic ovarian syndrome: more than just hirsutism
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- Authors
- Ezeh, U., Yildiz, B. O., & Azziz, R.
- Affiliations
- Cedars-Sinai Medical Center (US)
- Department of Internal Medicine, Endocrinology, and Metabolism Unit (B.O.Y.), Hacettepe University School of Medicine, Hacettepe, 06100 Ankara, Turkey
- University of California, Los Angeles (US)
- Corresponding author
- Azziz, Ricardo
- Venue
- The Journal of Clinical Endocrinology & Metabolism
- Publisher
- The Endocrine Society
- Published
- 2013-06-01
- Volume
- 98
- Issue
- 6
- Pages
- E1088-E1096
- ISSN
- 0021-972X (ISSN-L)
- 1945-7197
- PMC
- PMC3667270
- OpenAlex
- W2040201798
- Cited by
- 193
- References
- 42
- Citations by year
- 2026: 9 · 2025: 13 · 2024: 19 · 2023: 22 · 2022: 14 · 2021: 13 · 2020: 13 · 2019: 10 · 2018: 19 · 2017: 10 · 2016: 16 · 2015: 15 · 2014: 14 · 2013: 6
- FWCI
- 20.60
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- The Journal of Clinical Endocrinology & Metabolism (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Hacettepe University Institutional Repository (hacettepe.edu.tr) (submittedVersion, other-oa)
- Funders
- National Institutes of Health (K24-HD01346, 1-K24-HD01346)
- National Institute of Diabetes and Digestive and Kidney Diseases (R01DK073632)
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (K24HD001346, R01HD029364, 1-K24-HD01346, R01-HD29364)
- Topics
- Health Sciences › Medicine › Reproductive Medicine › Ovarian function and disorders
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Genetics › Genetic and Kidney Cyst Diseases
- Keywords
- polycystic ovary syndrome, referral bias, obesity prevalence, PCOS phenotypes, hyperandrogenemia, hirsutism, body mass index, racial and ethnic differences, disease severity
- MeSH terms
- Adult, Female, Humans, Obesity, Phenotype, Polycystic Ovary Syndrome, Referral and Consultation, Bias, Body Mass Index, Prevalence, Hyperandrogenism
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