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\begin{document}

\title{THE RELIABILITY AND VALIDITY OF MALAY VERSION OF POLYCYSTIC OVARIAN
SYNDROME HEALTH RELATED QUALITY OF LIFE QUESTIONNAIRE (MAL-PCOSQ)}



\author[1]{Leek Mei Lim}%
\author[2]{Ana Vetriana Abd Wahab}%
\author[3]{Nur Azurah Abdul Ghani}%
\affil[1]{Hospital Sultanah Aminah}%
\affil[2]{Sabah Women and Children's Hospital}%
\affil[3]{Hospital Canselor Tunku Mukhriz}%


\vspace{-1em}



  
  \date{May 15, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
ABSTRACT Background: The Polycystic Ovary Syndrome health related
Questionnaire (PCOSQ) is a reliable instrument for measuring the health
related quality of life (HRQoL) in women with polycystic ovary
syndrome(PCOS). The study is aimed to develop a Malay version of PCOSQ
(Mal-PCOSQ) to evaluate the HRQoL of Malaysian women with PCOS and to
test its reliability and validity. Methods: Participants were women who
were diagnosed with PCOS attending the gynaecology clinic. Reliability
was determined by internal consistency using Cronbach's coefficient
alpha and test-retest reliability using intra-class correlation
coefficient. Validity was assessed through convergent and discriminant
validity. Examining the correlation between similar content on the
Mal-PCOSQ and the Short Form 36 version 2 (SF 36v2) assessed convergent
validity. Whereas the discriminant validity was assessed using the known
groups comparison. Results: Cronbach's coefficient alpha was over 0.70
for total scale and over 0.60 for each subscale. Known groups comparison
support its discriminant validity whereby the Mal-PCOSQ differentiated
well between sub-groups of women who differ in PCOS specific symptoms.
Convergent validity was consistent with a good positive correlation
between related subscales of the two instruments. Women with PCOS in
Malaysia scored lowest for weight (3.74) and infertility (3.41) domains
indicating worse health in these domains. Body hair (5.42) was the least
troublesome for the local population. Conclusion: The Mal-PCOSQ is
reliable and valid tool in assessing the health related quality of life
and can be used to objectively assess the HQoL of Malaysian women with
PCOS and evaluate their responsiveness to treatment.%
\end{abstract}%



\sloppy


\textbf{THE RELIABILITY AND VALIDITY OF MALAY VERSION OF POLYCYSTIC
OVARIAN SYNDROME HEALTH RELATED QUALITY OF LIFE QUESTIONNAIRE
(MAL-PCOSQ)}

\textbf{LEEK MEI} LIM\textsuperscript{1,4}

\textbf{ANA VETRIANA} ABD WAHAB\textsuperscript{2,5}

\textbf{ABDUL GHANI} NUR AZURAH\textsuperscript{3,6}

\textsuperscript{1}MBBS(Manipal), MRCOG(UK), DrObGyn(UKM)

\textsuperscript{2}MD(USM),DrObGyn(UKM), Repromed(MAL-BEL), IFEPAG(AUS),

\textsuperscript{3}MBBS(Malaya), MOG(UKM), MD(melb), IFEPAG (fellow)

\textsuperscript{4}Hospital Sultanah Aminah, Johor Bahru

\textsuperscript{5}Sabah Women and Children's Hospital

\textsuperscript{6}UKM Medical Center

*Corresponding author

Dr Lim \textbf{Leek Mei}

Obstetrician and Gynaecologist

Hospital Sultanah Aminah Johor Bahru, Malaysia

Email : drleekmei@gmail.com

\textbf{ABSTRACT}

\textbf{Background:} The Polycystic Ovary Syndrome health related
Questionnaire (PCOSQ) is a reliable instrument for measuring the health
related quality of life (HRQoL) in women with polycystic ovary
syndrome(PCOS). The aim of this study was to develop a Malay version of
PCOSQ (Mal-PCOSQ) to evaluate the HRQoL of Malaysian women with PCOS and
to test its reliability and validity.

\textbf{Methods:} Participants were women who were diagnosed with PCOS
attending the gynaecology clinic. Reliability was determined by internal
consistency using Cronbach's coefficient alpha and test-retest
reliability using intra-class correlation coefficient. Validity was
assessed through convergent and discriminant validity. Examining the
correlation between similar content on the Mal-PCOSQ and the Short Form
36 version 2 (SF 36v2) assessed convergent validity. Whereas the
discriminant validity was assessed using the known groups comparison.

\textbf{Results:} Cronbach's coefficient alpha was over 0.70 for total
scale and over 0.60 for each subscale. Known groups comparison support
its discriminant validity whereby the Mal-PCOSQ differentiated well
between sub-groups of women who differ in PCOS specific symptoms.
Convergent validity was consistent with a good positive correlation
between related subscales of the two instruments. Women with PCOS in
Malaysia scored lowest for weight (3.74) and infertility (3.41) domains
indicating worse health in these domains. Body hair (5.42) was the least
troublesome for the local population.

\textbf{Conclusion:} The Mal-PCOSQ is a reliable and valid tool to
assess the health related quality of life among local population. It can
be used to objectively assess the HQoL of Malaysian women with PCOS and
evaluate their responsiveness to treatment modalities.

\textbf{KEYWORDS :} Polycystic Ovary Syndrome (PCOS), PCOS, Polycystic
Ovary Syndrome Questionnaire(PCOSQ), PCOSQ, Malay version PCOSQ,
Mal-PCOSQ, health related quality of life, HQoL.

\textbf{BACKGROUND}

Polycystic ovary syndrome (PCOS) is the commonest endocrine condition
that affect women with an estimated prevalence of 10--15\%{[}1-4{]}.
PCOS is associated with reproductive and general health implications. It
has a broad spectrum of clinical presentation with varying severity. It
commonly presents as menstrual disturbances, hyperandrogenism, i.e:
hirsutism, acne and alopecia, subfertility, obesity and psychological
disturbances.{[}1{]}PCOS has been showed to have profound impact on a
woman's psychological wellbeing{[}5{]}. In 2003, the diagnosis of PCOS
was proposed by the European Society for Human Reproduction and
Embryology (ESHRE) and the American Society of Reproductive Medicine
(ASRM) after a consensus meeting held in Rotterdam; the criteria were :
the presence of (1) clinical or biochemical features of
hyperandrogenism, (2) oligo-ovulation or anovulation (i.e. menstrual
cycle disturbance) and/or (3) polycystic ovaries on ultrasound. PCOS is
diagnosed when a women fulfil 2 out of 3 of these criteria and
appropriate investigations have been performed to exclude other possible
causes of menstrual disturbance and androgen excess.{[}1{]}

The symptoms associated with PCOS have led to significant reduction in
health-related quality of life (HRQoL). The affected aspect of HRQoL
differ individually as each woman may present with different concerns
related to PCOS. Adult women are mainly concerned about subfertility
issues and hirsutism whereas adolescents are more likely to worry about
acne and weight gain.

The impact of PCOS towards quality of life also differ among different
ethnicity and background. Symptoms that are commonly associated with
PCOS, such as acne, hirsutism, irregular menses, amenorrhea, obesity,
and subfertility, are the major sources of psychological and behavioural
disorder, and these clinical presentations varies in their impact on
different ethnic groups. Cronin et-al{[}6{]} found that infertility and
emotions subscales in the original PCOSQ has the highest impact score
among African-American women with PCOS, whereas Huang-et-al {[}2{]} had
showed that the burden of hirsutism on HRQoL in South Asians was less
than that in Caucasians. On the other hand, weight and infertility were
the worst domains on the condition-specific questionnaire using the
validated Chinese version of PCOSQ. The Iranian study{[}7{]} findings
showed that Iranians PCOS patient with more hirsutism, acne, menstrual
irregularities, infertility and weight issues, will score poorer HRQoL
compared to patient without these clinical symptoms.

Till date, validation of the Malay version has not be conducted hence no
data on the HRQoL of the Malaysian population is available. The aim of
this study was to demonstrate the reliability and validity of the Malay
version of PCOSQ. Furthermore, this questionnaire would allow
comparisons of results between different regions hence leading to
improvement of HRQoL of women with PCOS by giving more targeted
treatment.

\textbf{METHODS:}

\textbf{Scale development}

The ethical approval was obtained from the Secretariat for Medical
Research \& Innovation (SPPI), National University of Malaysia
(FF-2018-020).

The original PCOS health related questionnaires (PCOSQ) is published in
Journal of Clinical Endocrinology and Metabolism by The Endocrine
Society in 1998{[}5{]}. The permission to translate the original
questionnaires was obtained through the Copyright Clearance Centre.

Two Malay translators competent in English from Malaysian National
Institute Of Translations translated the PCOSQ into Malay language
independently. Following the forward translation, discussion was held
between the translators to develop a single Malay version. Following
that, two other translators who were both blinded from the original
version performed backward translation from Malay to English. The
original English version and translated version were assessed by a group
of experts for any discrepancies. No major discrepancy was noted.

Pretest was conducted on 20 women to assess face validity ; their
response and understanding on each question. Also to time the duration
needed to complete the questionnaire.

\textbf{Study population}

This study was conducted in the gynaecology clinic of the study
institute between December 2017 and June 2018. All women age 18 to
45years diagnosed with PCOS following Rotterdam's criteria were
eligible. Women with psychiatric illness were excluded from the study.
Written consent was obtained prior to recruitment.

\textbf{Study tools and procedure}

\textbf{SF-36v2}

The SF-36v2 is the latest version of SF36 which is a generic indicator
of health status and has been applied in assessing outcomes of various
health conditions in the general population. The instrument has been
tested for validity and reliability. The SF 36 v2 measures and includes
8 subscales: physical functioning (PF), role limitations due to physical
problems (RP), bodily pain, general health perception (GH), social
functioning (SF), role limitations due to emotional problems (RE),
vitality (VT), and mental health (MH). The score for each subscale range
from 0-100 where higher scores indicate better conditions. A Malay
version is available and has been shown to be reliable and valid for
use{[}8{]} ( Appendix S1).

\textbf{Mal-PCOSQ}

The original PCOS health related quality of life questionnaire is in
English language, published by Cronin L et al. in 1998 in the U.S.A.
which includes 26 items in 5 domains and it takes 10-15 minutes to
complete.{[}6{]} The domains are divided into emotions (8 items), body
hair (5 items), weight (5 items), infertility (4 items), and menstrual
problems (4 items); Each question is associated with a 7-point scale in
which 7 represents optimal function and 1 represents the poorest
function. Analysis from this study{[}6, 9{]} found that this PCOSQ is
easy to understand and use. It is recommended that investigators weigh
the items equally and present the results as the mean score per item for
each of the domains.{[}6, 9{]} (Appendix S2)

\textbf{Ferriman Gallway score}

Hirsutism is assessed clinical by using a pictorial scoring system of
nine areas of body. A score of 0 indicates no terminal hair whereas a
score of 4 indicates severe hirsutism. A total score of 7 or more
signify hirsutism. (Appendix S3)

\textbf{Menstrual history}

The duration, amount of flow, regularity and length of the cycle were
documented.

\textbf{Infertility history}

History of subfertility and its duration were documented.

\textbf{Body mass index (BMI)}

BMI was calculated from the measurement of weight and height is all
patients.

BMI = weight / height\textsuperscript{2} (m/kg\textsuperscript{2})

Eligible women were asked to complete the sets of questionnaires that
include SF-36v2 and Mal-PCOSQ while waiting to see the doctor. They were
also asked to complete the socio-demographic information, menstrual
history, fertility status and body hair. The height, weight, blood
pressure and waist circumference were recorded. Collected questionnaires
were checked for completeness.

\textbf{Statistical analyses}

Reliability of the Mal-PCOSQ was assessed by internal consistency using
Cronbach's alpha. A value of \textgreater{}0.70 was considered
acceptable. Discriminant validity was assessed using known groups
comparison to test as whether Mal-PCSOQ were able to differentiate
between subgroups that differed in body hair, menstrual irregularities,
subfertility and BMI. To test for convergent validity, it was
hypothesized that there would be a strong correlation between emotional
disturbances domain of the Mal-PCOSQ with the role-emotional and mental
health domains of SF-36v2. Correlation value of \textgreater{}0.40 was
considered as good. For descriptive analyses, the mean, standard
deviation, minimum and maximum scores and skewness were calculated. All
statistical analyses of the study were conducted by SPSS 20.0
Windows(SPSS,Inc,USA) and significance level was set at 0.05.

\textbf{RESULTS}

A total of 138 participants were recruited and all completed the
questionnaires with no missing data. The mean age of patients was
31.5\selectlanguage{ngerman}±4.6 years. Majority were Malay which comprises of 84.8\%, followed
by Chinese (8\%), and Indian (7.2\%). A vast majority were obese
(81.2\%) with the mean BMI of 30.6±6.56kg/m\textsuperscript{2} and mean
waist circumference of 33.28±4.44 cm. About 59.7\% had irregular cycles
and 53.6\% had Ferriman Gallway score of \textgreater{} 8.
Socio-demographic characteristics are shown in Table 1.

\textbf{Reliability}

The internal reliability test is shown in Table 2. The Cronbach's alpha
was above 0.70 with all domains above 0.80 except for menstrual problem
domain that had Cronbach's alpha of 0.678, which implied satisfactory
reproducibility. To evaluate the test-retest reliability of these
questionnaires, re-administered of questionnaires was given 1-2 weeks of
completion of the initial responds. Intra-class correlations (ICC) was
calculated to assess the test- retest reliability of Mal-PCOSQ.{[}10,
11{]} The overall test- retest results showed good interclass
correlation as all domains were above 0.70 as shown in Table 3. Hence we
concluded the overall Mal-PCOSQ has good reliability.

\textbf{Type of HRQoL impairment}

The distribution of scores for Mal-PCOSQ and SF-36 are listed in Table
4. The lowest scores for Mal-PCOSQ were reported in the weight (3.74)
and infertility (3.41) domains indicating worse health in these domains.
Body hair (5.42) was the least concerning issue. For SF-36v2, the mental
component summary (44.83) and physical component summary (50.15) were
both rated low. The highest mean score was seen in physical function
(78.51) while vitality (55.75) and general health (57.42) were scored
the lowest. The percentage of women who scored at lowest level (i.e.
floor effect) and at highest level (i.e. ceiling effect) was small.

\textbf{Validity}

Discriminant validity was assessed using known groups comparison. It is
shown that Mal-PCOSQ was able to discriminate women who differed in PCOS
specific symptoms hence support the validity the Mal-PCOSQ (Table 5). As
hypothesized, good correlation was found between similar domains of the
two instruments used ; Mal-PCOSQ and SF-36v2 (Table 6). Emotional domain
on Mal-PCOSQ was well correlated with role emotion (r=0.469;
p\textless{}0.001), social function (r=0.464; p\textless{}0.01), mental
health (r=0.476; p\textless{}0.01) and mental component summary
(r=0.545; p\textless{}0.01) of SF-36v2. These correlations were stronger
than the other domains, for example physical function (r=0.252).
Menstrual problems domain on Mal-PCOSQ correlated with Bodily pain
domain of SF-36v2 (r=0.439; p\textless{}0.01). Infertility domain of
Mal-PCOSQ correlated significantly with role emotion of SF-36v2
(r=0.423; p\textless{}0.01) that indicates infertility posed a
significant impact on emotions of women with PCOS.

\textbf{Predictors of low scores}

Age is predicted to be predictor score of emotions subscale (p=0.192,
p=0.048) and infertility subscale (p=0.209, p=0.027) of the Mal-PCOSQ,
which means in our population, the older the patient the lower the score
for emotion domain. Duration of infertility is also found to be
predictor score of infertility subscale of Mal-PCOSQ (p=-0.313,
p=0.001). The longer the duration of infertility, the lower the score of
infertility subscale. (Table 7)

\textbf{COMPARISON OF HRQOL OF MALAYSIAN WOMEN WITH PCOS WITH OTHER
COUNTRIES}

As compared to other ethnic origins, it is obvious that the domains
affected vary significantly (Figure S1). In UK populations {[}5, 12{]}
weight and infertility appear to be the main concerns while the
Iranian{[}7{]}, Chinese{[}2{]} and Malaysian score infertility the
lowest score. The Asians has least concern on body hair unlike the UK
population. This proves our hypothesis that PCOS affects different
ethnicity differently.

\textbf{DISCUSSION:}

The present study provides evidence of reliability and validity testing
of Mal-PCOSQ. The present study shows that Malaysian women with PCOS are
affected by their condition as evidence by low scores firstly in
infertility and then followed by weight domain. Body hair has highest
score and was the least concern in the local population. Present study
was more similar to that of Huang-et-al{[}2{]}, which is of similar
Asian population. Huang-et-al{[}2{]} had showed that the burden of
hirsutism on HRQoL in South Asians was especially to a lesser extent
than that in Caucasians, with weight being the worst domain, followed by
infertility using the validated Chinese version of PCOSQ. Cronin
et-al{[}6{]} found that emotions has lowest score however in contrast to
present study, infertility subscales were the second most affected. It
also has the highest impact score among African-American women with PCOS
compare to the white caucasians. On the other hand, the Iranian
study{[}7{]} findings showed that Iranians patients were more affected
firstly by infertility and then menstruation. Interesting to see,
regardless of ethnicity, infertility seems to affect patients with PCOS
tremendously regardless of ethnicity.{[}13{]} However the second most
affected domains varies among different populations which may be due to
different cultures and social expectations. This is may be due to the
fact that these PCOS patients were recruited in gynaecology clinic,
hence infertility is the most common clinical complaint among them.

There was no dropout in our study as the investigator prior to
collecting the forms checked the questionnaires. None of the patients
has difficulties in understanding the questions in Malay hence
indicating that Mal-PCOSQ was feasible to be use in local population.
All the coefficients of the Mal-PCOSQ domains are analysed using
test-retest reliability analysis which proves a good reliability with
Croncbach alpha \textgreater{}0.7; with average of 0.852.

The floor and ceiling effects were small in all subscales of Mal-PCOSQ
when compared with SF-36v2. These indicate that the instrument was more
specific towards certain areas pertaining to the disease or condition
itself, which was better than the generic instrument.

The SF 36v2 questionnaire analysis showed both mental and physical score
summary are low, with former 44.83 and later 50.15 which showed that our
PCOS patients are significantly affected in both mental and physical
health which supported the findings of Mal-PCOSQ which again enhanced
the validity of Mal-PCOSQ. The convergent validity of the Mal-PCOSQ was
proven by its correlation with similar domains in SF-36v2 whereby the
`emotion' domain (Mal-PCOSQ) correlated well with the `role emotion' and
`mental health' of SF-36v2. Known group comparisons which were obesity,
hirsutism, irregular menses and subfertility indicate that Mal-PCOSQ
were able to differentiate between subgroups with different clinical
features hence proved its discriminant validity of the instrument.

Infertility and weight appear to be the most affected components in our
study population. Patient who has infertility score the domain on
Mal-PCOSQ lowest (p=0.006) while obese patients also has significant
impact on weight domain on Mal-PCOSQ (p=0.000).(Table 5)

The Mal-PCOSQ can potentially be used upon the diagnosis of the disease
and during follow-ups to ascertain which component that affect the
patient most and assess the efficacy of the treatment provided. No
doubt, this will further improve patients care and outcome as each
patient's management is tailored management to cater for her
needs.{[}12{]}

\textbf{LIMITATIONS :}

Limitations of this study is that it may not be representative of the
Malaysian population as participants were recruited from one centre only
as such populations were limited to single center. Bigger study can be
done including other centers to further investigate the strength of this
questionnaire as well as study the effect of PCOS on different
population, example in the indigenous group or in adolescent group.
Future study can expand the domains of Mal-PCOSQ by adding acne question
which was proven to be significantly affected in the Chinese
population{[}2{]}.

\textbf{CONCLUSION:}Mal-PCOSQ is reliable and valid instrument that can
be potentially used to assess the effect of PCOS on quality of life as
well as to assess the efficacy of treatment in follow ups consultations.

\textbf{Conflict of interest :} There is no conflict of interest
associated with this publication , and there has been no significant
financial support for this work that could have influenced its outcome.

\textbf{Contribution of Authors :}

Prof Dr Nur Azurah is the main person who conceived the topic of this
project. All authors were involved in planning, executing and
supervising the work. Dr Ana Vetriana and Dr Leekmei processed the
experimental data and performed the analysis. Dr Leekmei drafted the
manuscript which was overlooked by Prof Dr Nur Azurah and Dr Ana
Vetriana whom critically appraised the manuscript and corrected any
mistakes and thus improved on shortfalls.

All authors aided in interpreting the results and worked on the
manuscript. All authors discussed the results and commented on the
manuscript.

\textbf{Ethics approval} : This study is approved by the Secretariat for
Medical Research \& Innovation (SPPI), National University of Malaysia
(FF-2018-020). The letter of approval (UKMFPR.4/244/FF-2018-020) was
issued on 16 January 2018.

\textbf{Funding :} No external funding was received. All the costs
incurred was bear by the main author.

\textbf{REFERENCES:}

1. Group, R.E.A.S.P.C.W., \selectlanguage{english}\emph{Revised 2003 consensus on diagnostic
criteria and long-term health risks related to polycystic ovary syndrome
(PCOS).} Human reproduction, 2004. \textbf{19} (1): p. 41-47.

2. Ou, H.-t., et al., \emph{Development of Chinese version of polycystic
ovary syndrome health-related quality of life questionnaire
(chi-PCOSQ).} PloS one, 2015. \textbf{10} (10): p. e0137772.

3. Balen, A.H., \emph{Polycystic ovary syndrome (PCOS).} The
Obstetrician \& Gynaecologist, 2017. \textbf{19} (2): p. 119-129.

4. Fauser, B.C., et al., \emph{Consensus on women's health aspects of
polycystic ovary syndrome (PCOS): the Amsterdam ESHRE/ASRM-Sponsored 3rd
PCOS Consensus Workshop Group.} Fertility and sterility,
2012.\textbf{97} (1): p. 28-38. e25.

5. Jones, G., et al., \emph{Health-related quality of life measurement
in women with polycystic ovary syndrome: a systematic review.} Human
reproduction update, 2007. \textbf{14} (1): p. 15-25.

6. Cronin, L., et al., \emph{Development of a health-related
quality-of-life questionnaire (PCOSQ) for women with polycystic ovary
syndrome (PCOS).} The Journal of Clinical Endocrinology \& Metabolism,
1998. \textbf{83} (6): p. 1976-1987.

7. Bazarganipour, F., et al., \emph{Iranian version of modified
polycystic ovary syndrome health-related quality of Life questionnaire:
Discriminant and convergent validity.} Iranian journal of reproductive
medicine, 2013. \textbf{11} (9): p. 753.

8. Ware, J., et al., \emph{sf-36v2 health survey: Administration guide
for clinical trial Investigators.} Lincoln, RI: QualityMetric
Incorporated, 2008: p. 1-34.

9. Jones, G., et al., \selectlanguage{english}\emph{The polycystic ovary syndrome health-related
quality of life questionnaire (PCOSQ): a validation.} Human
Reproduction, 2004. \textbf{19} (2): p. 371-377.

10. Donner, A. and M. Eliasziw, \emph{Sample size requirements for
reliability studies.} Statistics in medicine, 1987. \textbf{6} (4): p.
441-448.

11. Bujang, M.A. and N. Baharum, \emph{A simplified guide to
determination of sample size requirements for estimating the value of
intraclass correlation coefficient: a review.} Archives of Orofacial
Science, 2017. \textbf{12} (1).

12. Coffey, S., G. Bano, and H.D. Mason, \emph{Health-related quality of
life in women with polycystic ovary syndrome: a comparison with the
general population using the Polycystic Ovary Syndrome Questionnaire
(PCOSQ) and the Short Form-36 (SF-36).} Gynecological Endocrinology,
2006. \textbf{22} (2): p. 80-86.

13. Jones, G.L., et al., \emph{Do South Asian women with PCOS have
poorer health-related quality of life than Caucasian women with PCOS? A
comparative cross-sectional study.} Health and quality of life outcomes,
2010. \textbf{8} (1): p. 149.

\emph{TABLES}

\textbf{Table 1 : Socio-demographic characteristics}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
Socio-demographic characteristics & Socio-demographic characteristics &
Mean (SD) & Frequency (\%) N=138\tabularnewline
\midrule
\endhead
Age & Age & 31.50 (4.660) &\tabularnewline
Ethnicity & Ethnicity & &\tabularnewline
& Malay & & 84.8\%\tabularnewline
& Chinese & & 8.0\%\tabularnewline
& Indian & & 5.8\%\tabularnewline
& Punjabi & & 1.4\%\tabularnewline
BMI (kg/m\textsuperscript{2}) & BMI (kg/m\textsuperscript{2}) & 30.60
(6.56) &\tabularnewline
& Underweight (\textless{}18.9) & & 1.4\%\tabularnewline
& Normal (18.9-22.9) & & 8.7\%\tabularnewline
& Overweight (23-24.9) & & 8.7\%\tabularnewline
& Obese (\textgreater{}25) & & 81.2\%\tabularnewline
Waist Circumference (cm) & Waist Circumference (cm) & 33.28 (4.44)
&\tabularnewline
Menstrual cycle & Menstrual cycle & &\tabularnewline
& Regular & & 40.6\%\tabularnewline
& Irregular & & 59.4\%\tabularnewline
Ferriman Gallway score & Ferriman Gallway score & &\tabularnewline
& \textless{}8 & & 46.4\%\tabularnewline
& \textgreater{}8 & & 53.6\%\tabularnewline
Infertility problem & Infertility problem & &\tabularnewline
& No & & 21.0\%\tabularnewline
& Yes & & 79.0\%\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 2: Reliability test of Mal-PCOSQ}\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
Domains of MPCOSQ & Cronbach's Alpha\tabularnewline
\midrule
\endhead
Emotion & 0.876\tabularnewline
Body Hair & 0.927\tabularnewline
Weight & 0.916\tabularnewline
Infertility & 0.864\tabularnewline
Menstrual Problem & 0.678\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 3 : Test-retest of Mal-PCOSQ}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
& Cronbach Alpha & Cronbach Alpha & Test-Retest\tabularnewline
\midrule
\endhead
& Pre Test & Post Test &\tabularnewline
Emotions & 0.930 & 0.948 & 0.940\tabularnewline
Body Hair & 0.939 & 0.964 & 0.920\tabularnewline
Weight & 0.959 & 0.979 & 0.960\tabularnewline
Infertility & 0.926 & 0.899 & 0.971\tabularnewline
Menstrual Problem & 0.678 & 0.630 & 0.777\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 4 : Mal-PCOSQ and SF-36 Scores, floor and ceiling effects}\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
& Domains & Mean (SD) & 95\% CI & Minimum (\% floor) & Maximum (\%
ceiling)\tabularnewline
\midrule
\endhead
Mal-PCOSQ & & & & &\tabularnewline
& Emotions & 4.29 (1.29) & 4.07 - 4.50 & 1.4 & 1.4\tabularnewline
& Body hair & 5.42 (1.46) & 5.18 - 5.67 & 0.7 & 1.8\tabularnewline
& Weight & 3.74 (1.52) & 3.49 - 4.00 & 2.9 & 4.3\tabularnewline
& Infertility & 3.41 (1.47) & 3.16 - 3.63 & 4.3 & 2.2\tabularnewline
& Menstrual & 4.57 (1.25) & 4.36 - 4.78 & 0.7 & 3.6\tabularnewline
SF-36v2 & & & & &\tabularnewline
& Physical function & 78.51 (21.16) & 74.95 - 82.08 & 0.7 &
23.2\tabularnewline
& Role physical & 75.96 (23.32) & 72.03 - 79.88 & 0.7 &
36.2\tabularnewline
& Bodily pain & 69.78 (20.52) & 66.32 - 73.23 & 2.2 &
19.6\tabularnewline
& General health & 57.42 (18.98) & 54.23 - 60.62 & 0.7 &
0.7\tabularnewline
& Vitality & 55.75 (16.57) & 52.97 - 58.54 & 1.4 & 0.7\tabularnewline
& Social function & 71.29 (22.73) & 67.46 - 75.11 & 0.7 &
18.3\tabularnewline
& Role emotion & 75.42 (25.46) & 71.18 - 79.71 & 0.7 &
41.3\tabularnewline
& Mental health & 63.37 (16.54) & 60.59 - 66.15 & 0.7 &
1.4\tabularnewline
& PCS & 50.15 (6.84) & 48.00 - 51.30 & 0.7 & 0.7\tabularnewline
& MCS & 44.83 (9.13) & 43.30 - 46.37 & 0.7 & 0.7\tabularnewline
\bottomrule
\end{longtable}

PCS-Physical component score MCS-Mental component score

\textbf{Table 5: Mal-PCOSQ domain with different clinical parameters}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
Domains & Clinical parameters & Clinical parameters & P
value\tabularnewline
\midrule
\endhead
Body hair & FG score \textless{} 8 & FG score \textgreater{}8
&\tabularnewline
Mean (SD) & 5.8 (1.1) & 5.1 (1.7) & 0.003\tabularnewline
Weight & Normal BMI & Abnormal BMI &\tabularnewline
Mean (SD) & 5.23 (1.5) & 3.45 (1.3) & 0.000\tabularnewline
Infertility & No infertility & Presence of infertility &\tabularnewline
Mean (SD) & 4.1 (1.6) & 3.2 (1.4) & 0.006\tabularnewline
Menstrual & Regular menses & Irregular menses &\tabularnewline
Mean (SD) & 5.1 (1.2) & 4.2 (1.2) & 0.017\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 6: Construct validity : correlations between Mal-PCOSQ and
SF-36 questionnaires}\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
SF-36v2 & Mal-PCOSQ Domains (Correlation, p-value) & Mal-PCOSQ Domains
(Correlation, p-value) & Mal-PCOSQ Domains (Correlation, p-value) &
Mal-PCOSQ Domains (Correlation, p-value) & Mal-PCOSQ Domains
(Correlation, p-value)\tabularnewline
\midrule
\endhead
& Emotions & Body Hair & Weight & Infertility & Menstrual
Problem\tabularnewline
Physical function & 0.252 (0.003) & 0.275 (0.001) & 0.119 (0.163) &
0.148 (0.082) & 0.283 (0.001)\tabularnewline
Role physical & 0.372 (0.000) & 0.215 (0.011) & 0.232 (0.006) & 0.319
(0.000) & 0.384 (0.000)\tabularnewline
Bodily pain & 0.231 (0.007) & 0.265 (0.002) & 0.162 (0.058) & 0.145
(0.089) & 0.439 (0.000)\tabularnewline
General health & 0.328 (0.000) & 0.266 (0.002) & 0.249 (0.003) & 0.295
(0.000) & 0.367 (0.000)\tabularnewline
Vitality & 0.410 (0.000) & 0.308 (0.000) & 0.151 (0.078) & 0.328 (0.000)
& 0.388 (0.000)\tabularnewline
Social function & 0.464 (0.000) & 0.251 (0.003) & 0.287 (0.001) & 0.352
(0.000) & 0.445 (0.000)\tabularnewline
Role emotion & 0.469 (0.000) & 0.210 (0.013) & 0.297 (0.000) & 0.423
(0.000) & 0.390 (0.000)\tabularnewline
Mental health & 0.476 (0.000) & 0.284 (0.001) & 0.228 (0.007) & 0.387
(0.000) & 0.357 (0.000)\tabularnewline
PCS & 0.219 (0.10) & 0.286 (0.001) & 0.154 (0.072) & 0.138 (0.107) &
0.389 (0.000)\tabularnewline
MCS & 0.545 (0.000) & 0.259 (0.002) & 0.294 (0.000) & 0.469 (0.000) &
0.414 (0.000)\tabularnewline
\bottomrule
\end{longtable}

PCS-Physical Component Score MCS-Mental Component Score

\textbf{Table 7 : Domains of Mal-PCOSQ with predictors of low score}\selectlanguage{english}
\begin{longtable}[]{@{}llllllllllll@{}}
\toprule
\begin{minipage}[b]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.06\columnwidth}\raggedright\strut
Domains of Mal-PCOSQ, Mean (SD)\strut
\end{minipage} & \begin{minipage}[b]{0.06\columnwidth}\raggedright\strut
Domains of Mal-PCOSQ, Mean (SD)\strut
\end{minipage} & \begin{minipage}[b]{0.06\columnwidth}\raggedright\strut
Domains of Mal-PCOSQ, Mean (SD)\strut
\end{minipage} & \begin{minipage}[b]{0.06\columnwidth}\raggedright\strut
Domains of Mal-PCOSQ, Mean (SD)\strut
\end{minipage} & \begin{minipage}[b]{0.06\columnwidth}\raggedright\strut
Domains of Mal-PCOSQ, Mean (SD)\strut
\end{minipage} & \begin{minipage}[b]{0.06\columnwidth}\raggedright\strut
Domains of Mal-PCOSQ, Mean (SD)\strut
\end{minipage} & \begin{minipage}[b]{0.06\columnwidth}\raggedright\strut
Domains of Mal-PCOSQ, Mean (SD)\strut
\end{minipage} & \begin{minipage}[b]{0.06\columnwidth}\raggedright\strut
Domains of Mal-PCOSQ, Mean (SD)\strut
\end{minipage} & \begin{minipage}[b]{0.06\columnwidth}\raggedright\strut
Domains of Mal-PCOSQ, Mean (SD)\strut
\end{minipage} & \begin{minipage}[b]{0.06\columnwidth}\raggedright\strut
Domains of Mal-PCOSQ, Mean (SD)\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
Groups\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
Groups\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
Emotions\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
Emotions\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
Body Hair\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
Body Hair\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
Weight\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
Weight\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
Infertility\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
Infertility\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
Menstrual Problem\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
Menstrual Problem\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
CI\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
P value\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
CI\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
P value\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
CI\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
P value\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
CI\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
P value\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
CI\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
P value\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
Age\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.192 (0.001 to 0.106)\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.048\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.043 (-0.046 to 0.073)\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.657\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.077 (-0.037 to 0.087)\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.429\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.209 (0.008 to 0.124)\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.027\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.169 (-0.006 to 0.094)\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.082\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
Duration of Infertility\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
Duration of Infertility\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-0.089 (-0.127 to 0.46)\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.354\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-0.175 (-0.187 to 0.008)\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.070\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.004 (-0.099 to 0.102)\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.969\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-0.313 (-0.255 to -0.066)\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.001\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-0.069 (-0.110 to 0.052)\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.476\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

*CI : coefficient Interval

\selectlanguage{english}
\FloatBarrier
\end{document}

