Background: Hirsutism, or excessive terminal hair growth with a masculine pattern distribution, affects 60–70% of PCOS patients 

Aim: evaluate the effect of lifestyle modification intervention on hirsutism among infertile overweight and obese women with PCOs.

Subjects and Methods:  A quasi-experimental research design was used to study 116 infertile women at gynecological and infertility outpatient and inpatient clinics and specialized medical center for the treatment of infertility and delayed childbearing affiliated with Beni-Suef University Hospital in Egypt. The study utilized modified Ferriman-Gallwey (mFG) to determine the degree of Hirsutism.

Results: prior to the intervention, 51.7% of the study group exhibited significant hair growth in the upper abdomen and lower abdomen, but 58.6% of the study group had no visible terminal hair. 45% and 30% of the study group had moderate and severe hirsutism, respectively, before the intervention, compared to 23% and 11% after the intervention, respectively. Statistically significant association between hirsutism levels and lifestyle dietary habits after program implementation was found (p<0.05). Statistically significant association between physical activity level was observed after program implementation (p<0.05).

Conclusion: Lifestyle modification interventions have a significant positive effect on hirsutism levels for infertile overweight and obese women.

Recommendations: As counselors, nurses should offer advice and support as well as teach infertile overweight women about lifestyle change, since it presents a significant challenge in the modern society.

Since 1990, various diagnostic standards have been used to categorize PCOS. In 1990, the National Institutes of Health (NIH) established its criteria. A new diagnostic standard known as the Rotterdam criteria was developed in 2003 at a workshop in Rotterdam. The Androgen Excess Society (AES) updated the diagnostic standards and announced new standards in 2006. Another significant factor to take into account is the psychological health of the patient due to the impact of PCOS on physical appearance such as Hirsutism (Deswal et al., 2020; Hassan et al., 2019b; Mohamed & Hassan, 2020; Hassan & Farag, 2019).

Women with PCOS have been reported to have intrinsic theca cell malfunction, which results in excessive androgen synthesis and overexpressed luteinizing hormone (LH) receptors that are unaffected by endocrine or paracrine regulation (Zeng et al., 2020; Hassan et al., 2025). Additionally, androgens promote lipolysis, which raises the levels of free fatty acids in the blood, which leads to the development of insulin resistance and the development of abdominal obesity, particularly visceral obesity, which is frequent in women with PCOS. The effects of too much androgen on pertinent tissues; acne, male pattern baldness, and hirsutism are among other signs of hyperandrogenism (Di Lorenzo, et al., 2023; Mohamed et al., 2024; Hassan et al., 2015; Emem & Hassan, 2017).

Hirsutism, or excessive terminal hair growth with a masculine pattern distribution, affects 60–70% of PCOS patients (Kamenov & Gateva, 2020). The modified Ferriman-Gallwey (mFG) is the most widely used visual assessment technique to evaluate terminal hairs, which are pigmented, medullated hairs that would grow longer than 5 mm if unmolested (Willis et al., 2020; Hassan, 2019a; Nady et al., 2018a; Gamel et al., 2019).

In Egypt, there were 27.4% of women who had PCOS. Infertile women had a prevalence of 37.5%, whereas fertile women had a prevalence of 14%. Infertile patients with POCS had ovulatory disorders, hirsutism, and PCO in proportions of 73.3%, 60.4%, and 79.4%, respectively. PCOS prevalence and elevated BMI were significantly correlated (Sanad, 2014; Sheha et al., 2018; Nady et al., 2018b; Mohammed et al., 2018).

The modified Ferriman-Gallwey (mFG) evaluates the presence of terminal hair in nine areas of the body that are predominantly masculine: the upper lip, chin, and neck; the upper chest (excluding the nipples), upper abdomen (above the umbilicus), lower abdomen, thighs (front and/or back), upper back and upper arms. Each area is visually scored from zero (no terminal hair visible) to four (terminal hair consistent with a well-developed male) (John, 2021). A total score of zero denotes the absence of hirsutism, six to fifteen denotes mild hirsutism, and greater than fifteen denotes moderate to severe hirsutism. (Kamenov & Gateva, 2020; Hassan, 2020a).Treatment options for PCOS underlined are pharmacological, surgical intervention, and non-pharmacological interventions (Lifestyle interventions). 

1. Pharmacological treatment

a) Glucocorticoids: They can aid in preventing and managing hirsutism and enabling ovulatory cycles in patients with classic congenital adrenal hyperplasia when their usage is best justified (Davariya et al., 2022).

c) Gonadotropin-releasing hormone agonist (GnRHa): It improves hirsutism, inhibits pituitary hormones, and increases estradiol output while decreasing androgen (Calcaterra, et al., 2023).

1. Treatment for hirsutism

a) Direct hair removal therapy: For many years, the standard method was to get rid of extra hair in PCOS. It operates by inserting a small needle with an electrical current into the hair follicle. Although laser treatment is more expensive, less uncomfortable, and produces results much more quickly, the adverse effects are more severe (Davariya, et al., 2022).

b) Eflornithine hydrochloride: It is an inhibitor of the enzyme ornithine decarboxylase in human skin and has been approved for topical application in hirsutism (Rashid, et al., 2022).

1. Surgical treatment: 

Laparoscopic ovarian drilling, Bariatric surgery, and Assisted Reproductive Technology

1. Non-pharmacological interventions (Lifestyle interventions): 

The majority of PCOS patients said that they rarely obtain lifestyle recommendations from their therapists, although the majority of physicians support lifestyle changes for the management of PCOS (Nemchikova & Frontoni, 2022; Mostafa et al., 2018; Hassan, 2020b; Nady et al., 2017; Hassan, 2016).

Aim of the study: 

This study was conducted to evaluate the effect of lifestyle modification intervention on hirsutism among infertile overweight and obese women with PCOs.

Study hypotheses: 

Infertile overweight and obese women who will receive lifestyle modification interventions will experience an improvement and decrease hirsutism level.

Subject and methods:

Research design: A quasi-experimental design.

Study setting: The study was conducted at gynecological and infertility outpatient and inpatient clinics and specialized medical center for the treatment of infertility and delayed childbearing affiliated with Beni-Suef University Hospital.

Sample type and size:

A purposive sample 116 infertile overweight and obese women who attended the previously mentioned sitting will be selected, and fulfilled the following criteria:

Tools of data collection: Arabic Structured interviewing questionnaire divided into two parts:

Part I. Basic data and sociodemographic characteristics as telephone number, age, residence, marital status, employment, length in centimeters, weight in kilograms, waist circumference, and thigh circumference

Part II. Questions about Hirsutism; in the nine predominantly masculine body areas (androgen-dependent), such as the upper lip, chin and neck, upper chest (excluding the nipples), upper abdomen (above the umbilicus), lower abdomen, thighs (front and/or back), upper back, lower back, and upper arms, the presence of terminal hair (hairs that would grow >5mm in length if left unmolested, are typically pigmented, and are medullated) was assessed (Kahraman & Erdoğan, 2021).The participants' level of hirsutism was assessed using the modified Ferriman-Gallwey (mFG), which rates the nine mainly masculine body locations for terminal hair. Visual scores ranging from one (little unseen hair development) to four (extremely thick hair) were applied to each place (Kahraman & Erdoğan, 2021).

Scoring system: The total score was adopted from Kahraman & Erdoğan (2021) and assessed by summation of sub-scores in the nine areas:

• A total score of ≤33.3% indicates no or mild hirsutism (0-12)
• A total score of >33.3%-66.6% indicates moderate hirsutism (>12-24)
• A total score >66.6%-100% indicates severe hirsutism (>24-36)

Ethical Considerations:

Official approval will be obtained from ethical and research counsels that were approved by the Faculty of Nursing, Menoufia University Counsel. Informed oral consent was obtained from all women after an explanation of the nature and purpose of the study. 

Field Work: 

The study aimed to evaluate the impact of a lifestyle modification intervention on hyper-androgenic infertile overweight and obese women. The research involved a comprehensive review of literature, including textbooks, articles, journals, and websites. The study also involved interviews and assessments to assess socio-demographic characteristics, lifestyle habits, and baseline measures related to hyper-androgenism. The intervention was implemented in training halls, aiming for a 5-10% weight loss or a BMI < 29>

Statistical Analysis: -

Data was entered and analyzed using SPSS (version 25). Graphics were done using the excel program as well as the SPSS package. The level of significance was set at a P value of <0>

Figure 1 showed that while 48.3% of women with polycystic ovarian syndrome had no apparent terminal hair, 26% of infertile, overweight, and obese women had severe upper lips. According to the study, 58.6% of the control group had moderate hirsutism both before and after the intervention, compared to 29.3% of the study group who had severe hirsutism in their neck and chin. Before the intervention, 67.2% of the study and control groups, excluding the nipples, had no terminal hair visible on the upper chest; after the intervention, this number increased to 77.6%. 

                                       Figure 1: hirsutism among the Studied Infertile Overweight and Obese Women with Polycystic Ovary Syndrome

Furthermore, prior to the intervention, 51.7% of the study group exhibited significant hair growth in the upper abdomen (above the umbilicus) and lower abdomen, but 58.6% of the study group had no visible terminal hair, and 67.2% and 75.6% of the study groups, respectively, had no terminal hair visible on the thighs (front and/or back) before and after the intervention. Furthermore, before and following the intervention, there was no discernible terminal hair on the upper back, lower back, or upper arms in 75.9% and 86.2% of the research groups, respectively.

Table 1 shows the shows the total hirsutism levels among the studied infertile, overweight, and obese women with polycystic ovary syndrome. It presents that 45% and 30% of the study group had moderate and severe hirsutism, respectively, before the intervention, compared to 23% and 11

Figure 1 showed that while 48.3% of women with polycystic ovarian syndrome had no apparent terminal hair, 26% of infertile, overweight, and obese women had severe upper lips. According to the study, 58.6% of the control group had moderate hirsutism both before and after the intervention, compared to 29.3% of the study group who had severe hirsutism in their neck and chin. Before the intervention, 67.2% of the study and control groups, excluding the nipples, had no terminal hair visible on the upper chest; after the intervention, this number increased to 77.6%. 

                                       Figure 1: hirsutism among the Studied Infertile Overweight and Obese Women with Polycystic Ovary Syndrome

Furthermore, prior to the intervention, 51.7% of the study group exhibited significant hair growth in the upper abdomen (above the umbilicus) and lower abdomen, but 58.6% of the study group had no visible terminal hair, and 67.2% and 75.6% of the study groups, respectively, had no terminal hair visible on the thighs (front and/or back) before and after the intervention. Furthermore, before and following the intervention, there was no discernible terminal hair on the upper back, lower back, or upper arms in 75.9% and 86.2% of the research groups, respectively.

Table 1 shows the shows the total hirsutism levels among the studied infertile, overweight, and obese women with polycystic ovary syndrome. It presents that 45% and 30% of the study group had moderate and severe hirsutism, respectively, before the intervention, compared to 23% and 11

The current study findings revealed that nearly half and more than one-third of the study and control groups had moderate hirsutism before the intervention, respectively. After the intervention, about two-thirds of the study group had no terminal hair visible. Meanwhile, there were no statistically significant differences between study and control groups, neither before nor after the intervention.

These findings came in agreement with Niranjani et al. (2022), who studied "Effectiveness of cinnamon, exercise, and counseling on hyperandrogenic symptoms and level of anxiety among young girls with olycystic ovarian syndrome." They revealed that on the Modified Ferriman Gallwey scale (Hirsutism), during Pre-test through Post-test 2, the non-interventional group showed no improvement in score, whereas group A and group B showed a 1 score decrease.

On the contrary, these findings were inconsistent with those of Pramod et al. (2023), who studied dietary and physical activity patterns in PCOS women and found that less than one-quarter of respondents had dark hair growth. These differences might be attributed to the different populations in their study on overweight and obese women with PCOS.

The current study findings revealed that there is an improvement in lifestyle and daily habit levels among the studied hyper-androgenic infertile overweight and obese women. It reveals that most of the study and control groups had poor habits before the intervention, which improved to most of the study, and less than one-third of the control group had good habits after the intervention, respectively.

These results came in agreement with These findings came in agreement with Eleftheriadou et al. (2015), who study “Dietary Habits in Adolescent Girls with Polycystic Ovarian Syndrome" and found that poor eating habits were demonstrated in this group of adolescent PCOS patients, and this may contribute to the development of obesity in later life. Increased body weight increases long-term health risks and should be tackled with lifestyle interventions early in life.

Regarding total physical activity levels among the studied hyper-androgenic infertile overweight and obese women. The current study findings revealed that there is an improvement in total physical activity. Most of the study and control groups had mild physical activity (sedentary lifestyle) before the intervention, compared to two-thirds of the study group after the intervention having moderate physical activity. There is a statistically significant difference between the study and control groups after the intervention.

But in disagreement with the current study, Zhang et al. (2018) did not find differences in physical activity between the PCOS and control groups. Also, the current study is supported by Mutsaerts et al. (2013), who revealed that women with PCOS did not show a different change in lifestyle and moderate to vigorous physical activity compared with non-PCOS obese controls. This disagreement may be attributed to the type and intensity of physical activity.

The current study findings revealed that there is a statistically significant association between hyper-androgenic features (Hirsutism, acne, and alopecia) improvement and lifestyle habits in the study group of hyper-androgenic infertile overweight and obese women.

A meta-analysis indicated that hirsutism and menstruation dysfunction were the two aspects of quality of life most affected by PCOS; however, a more recent systematic review discovered that infertility and weight issues were the two factors most detrimental to HRQoL (Naumova et al., 2021). In addition, a recent study found that women with PCOS are 40% more likely to attempt suicide and are more likely to have personality disorders, schizophrenia, or bipolar illness (Farajzadegan et al., 2023). 

Significant improvements in hirsutism can be achieved with lifestyle changes (diet and exercise) that result in a small to moderate weight loss of about 5%-10% (Cowan & Moran, et al., 2023).

Lifestyle modification interventions have a significant positive effect on hirsutism levels for infertile overweight and obese women.

1. As counselors, nurses should offer advice and support as well as teach infertile overweight women about lifestyle change, since it presents a significant challenge in the modern society.
2. Establish nurse education and information programs grounded in research regarding the causes, symptoms, and handling of PCOs.