Temporal Trend Analysis of the Incidence of Polycystic Ovary Syndrome from 1990 to 2023 and Its Projection to 2030 in Iran

BRIEF TEXT

Background and Objective

Polycystic ovary syndrome (PCOS), one of the most common endocrine disorders in women of reproductive age, has significant implications for public health, fertility, and quality of life of affected individuals [1, 2]. This syndrome, characterized by diverse clinical manifestations including menstrual irregularities, hyperandrogenism, obesity, and insulin resistance, can predispose individuals to long-term complications such as type 2 diabetes, cardiovascular diseases, and psychological disorders [3-5]. As a multifaceted condition with reproductive, metabolic, and psychological manifestations, its impacts persist throughout the individual's lifespan [6]. A systematic review of reputable databases reported a pooled prevalence of approximately 21% for this syndrome, with an increasing trend over the past decade [7]. Lifestyle changes, environmental and nutritional factors, as well as increased awareness and timely diagnosis, have contributed to this rising trend [8, 9]. .... [7]. ..... [10]. In Iran, given the young population structure and the importance of women's health during reproductive years, investigating the spatiotemporal pattern of this syndrome is of paramount importance. This study aimed to investigate the temporal trend of age-standardized incidence rates of PCOS across Iranian provinces from 1990 to 2023 and to project these rates through 2030.

Materials and Methods

In this ecological study, provincial-level PCOS incidence data from 1990 to 2023 were extracted from the 2023 Global Burden of Disease Study. To model the temporal trend and forecast through 2030, a parametric autoregressive integrated moving average (ARIMA) modeling approach based on the Box-Jenkins framework was employed. All statistical analyses were performed using R software at a significance level of 0.05.

Results

The study revealed a distinct age-dependent distribution of PCOS incidence in Iran, with the highest rates observed in adolescent age groups 10–14 years (498.5 and 15–19 years (424.3 per 100,000 women in 2023), followed by a sharp decline after age 20, reaching below 20 cases in the 20–24 age group (Figure 1). The national age-standardized incidence rate increased significantly by 31% from 63.8 in 1990 to 83.5 in 2023, with the most pronounced increases in younger age groups (38% in 10–14 years and 28% in 15–19 years), while trends in women over 25 remained stable or slightly decreased. Geographically, substantial inter-provincial heterogeneity was observed, although the provincial gap narrowed considerably from 25.4 units in 1990 (range: 50.7-76.0) to 16.6 units in 2023 (range: 73.7-90.3). In 2023, the provinces of Tehran (90.3), Alborz (88.2), and Mazandaran (87.7) had the highest incidence rates, while the provinces of Sistan and Baluchistan (73.7) and Kurdistan (78.0) had the lowest. However, trend analysis over the 34 years revealed a more complex picture: Sistan and Baluchistan Province, Iran, experienced the highest absolute increase of 23 units (from 50.7 to 73.7), representing the greatest added disease burden, while North Khorasan Province, Iran, showed the fastest relative growth rate of 44% (from 56.3 to 81.1). The rate of increase varied considerably across provinces, with North Khorasan, Sistan and Baluchistan, and Kurdistan Provinces, Iran, experiencing steep upward slopes (average annual increase >0.7 units). In contrast, more developed provinces, such as Tehran (14.3 units, 19%) and Alborz (14.8 units, 20%), showed milder increases despite their higher absolute rates. ARIMA models were successfully fitted for all 31 provinces, with optimal (p,d,q) structures predominantly falling into ARIMA (3,2,0) (9 provinces) and ARIMA (0,2,3) (17 provinces). Model adequacy was confirmed through AIC (range: 89.5–126) and statistical tests, with all series achieving stationarity after second-order differencing (P = 0.99 on the Augmented Dickey-Fuller test). Projections for 2030 indicated that Mazandaran will continue to have the highest incidence rate at 85.8 cases per 100,000 (95% confidence interval [CI]: 60.2–111.3), followed by the provinces of Alborz (84.8; 95% CI: 59.0–110.5) and Gilan (82.4; 95% CI: 57.5–107.3), while Sistan and Baluchistan Province, Iran, will maintain the lowest rate at 51.8 (95% CI: 19.7–83.9). Provinces with the highest historical growth rates (e.g., Sistan and Baluchistan Province, Iran) are projected to retain the lowest absolute rates in the future, while the northern provinces (Mazandaran, Gilan) and central provinces (Alborz, Tehran) will remain the main disease burden hotspots. The overall projection pattern indicates stabilization or very slight decline in incidence rates for most provinces by 2030, reflecting a logical continuation of the recent moderating trend (Table 1).

Discussion

The observed pattern of PCOS incidence concentrated in adolescent age groups is consistent with findings from studies in other countries and may be attributed to early puberty, hormonal changes during this period, and improved diagnostic detectability in recent years [11, 12]. … [11]. The significant increase in the national incidence rate can be attributed to widespread lifestyle changes, including high-calorie diets, reduced physical activity, increased obesity, increased awareness, and access to diagnostic services. The reduction in provincial disparities may reflect the spread of common risk factors at the national level, and improvements in health infrastructure and reporting in less developed provinces. .... [13-15].

A population-based cross-sectional study in Tehran using data from the Tehran Lipid and Glucose Study reported the prevalence of PCOS based on Rotterdam criteria at approximately 19.4% [16]. This study, which had a precise comparative criterion with a healthy control group, demonstrated that cardiometabolic characteristics are not uniform across different PCOS phenotypes. This important distinction between phenotypes emphasizes that the metabolic burden of PCOS in the Iranian population is not homogeneously distributed and is mainly concentrated in specific subgroups. Therefore, the results of the present study, which emphasize the overall increase in incidence, should be interpreted considering this phenotypic heterogeneity.

Nevertheless, the persistence of geographical heterogeneity and the predicted concentration of disease burden in more developed and more populous provinces (such as Tehran and Alborz Province, Iran) may reflect region-specific risk factors, including obesity and high-calorie diets, urbanization stress, environmental pollution, and greater access to diagnostic services [17-19]. However, the remarkable increase in incidence rates in less developed provinces, such as Sistan and Baluchistan and North Khorasan, is a warning sign indicating that lifestyle changes and environmental factors are affecting all regions of the country, although the absolute level of incidence in these regions is still lower.

The projected increasing trend in the near future emphasizes the necessity for early interventions and evidence-based public health planning. Focusing on adolescent age groups through the implementation of screening programs and healthy lifestyle education in schools and adolescent health centers is a key priority.

Conclusion

The present study demonstrates that PCOS is a growing public health problem in Iran with an increasing trend and a focus on adolescents and young women. Although the incidence rate at the national level is rising, its geographical pattern is evolving, and the disease burden is projected to remain concentrated in the northern and central provinces in the near future.

References

1. Joham AE, Norman RJ, Stener-Victorin E, Legro RS, Franks S, Moran LJ, et al. Polycystic ovary syndrome. lancet Diabetes & endocrinol. 2022;10(9):668-80. PMID: 35934017 DOI: 10.1016/S2213-8587(22)00281-9
2. Louwers YV, Laven JS. Characteristics of polycystic ovary syndrome throughout life. . Ther Adv Reprod Health. 2020:2633494120911038. PMID: 32518918 DOI: 10.1177/2633494120911038
3. Escobar-Morreale HF. Polycystic ovary syndrome: definition, aetiology, diagnosis and treatment. Nat Rev Endocrinol. 2018;14(5):270-84. PMID: 29569621 DOI: 10.1038/nrendo.2018.24
4. Palomba S, de Wilde MA, Falbo A, Koster MP, La Sala GB, Fauser BC. Pregnancy complications in women with polycystic ovary syndrome. . Hum Reprod Update. 2015;21(5):575–92. PMID: 26117684 DOI: 10.1093/humupd/dmv029
5. Lizneva D SL, Walker W, Brakta S, Gavrilova-Jordan L, Azziz R. Criteria, prevalence, and phenotypes of polycystic ovary syndrome. . Fertil steril. 2016;106(1):6-15. PMID: 27233760 DOI: 10.1016/j.fertnstert.2016.05.003
6. Behboodi Moghadam Z, Fereidooni B, Saffari M, A, M. Polycystic ovary syndrome and its impact on Iranian women’s quality of life: a population-based study. . BMC women's health. 2018;18(1):164. PMID: 30305063 DOI: 10.1186/s12905-018-0658-1
7. Deswal R, Narwal V, Dang A, Pundir CS. The prevalence of polycystic ovary syndrome: a brief systematic review. J hum reprod sci. 2020;13(4):261-71. PMID: 33627974 DOI: 10.4103/jhrs.JHRS_95_18
8. de Souza AT, da Silva Torres KL, Sarmento AC, de Lima AS, de Medeiros KS, de Souza Dantas D, Cobucci RN, Gonçalves AK, de Oliveira Crispim JC. Genetic association between microRNA gene polymorphisms and polycystic ovary syndrome susceptibility: A systematic review and meta‐analysis. Int J Gynecol Obstet. 2025 ;171(2):629-38. PMID: 40492548 DOI: 10.1002/ijgo.70255
9. Johnson C, Garipoğlu G, Jeanes Y, Frontino G, Costabile A. The role of diet, glycaemic index and glucose control in polycystic ovary syndrome (PCOS) management and mechanisms of progression. Curr Nutr Rep. 2025;14(1):8. PMID: 39753786 doi: 10.1007/s13668-024-00601-4
10. Yang R, Li Q, Zhou Z, Qian W, Zhang J, Wu Z, et al. Changes in the prevalence of polycystic ovary syndrome in China over the past decade. Lancet Reg Health West Pac. 2022;25. PMID: 35669932 DOI: 10.1016/j.lanwpc.2022.100494
11. Wang J, Wang B, Li C, Meng T, Liu C, Chen J, et al. Evolving global trends in pcos burden: a three-decade analysis (1990–2021) with projections to 2036 among adolescents and young adults. Front in Endocrinol. 2025;16:1569694. PMID: 40421239 DOI: 10.3389/fendo.2025.1569694
12. Lin L, Li W, Xu B, Li Y, Li J, Kong X, et al. Global trends in polycystic ovarian syndrome over 30 years: an age-period-cohort study of 204 countries and territories (1990–2021). J Health, Popul Nutr. 2025;44(1):242. PMID: 40629416 DOI: 10.1186/s41043-025-01002-1
13. van Keizerswaard J, de Loos AL, Louwers YV, Laven JS. Changes in individual polycystic ovary syndrome phenotypical characteristics over time: a long-term follow-up study. Fertil steril. 2022;117(5):1059-66. PMID: 35219451 DOI: 10.1016/j.fertnstert.2022.01.014
14. Peña AS, Witchel SF, Hoeger KM, Oberfield SE, Vogiatzi MG, Misso M,et al. Adolescent polycystic ovary syndrome according to the international evidence-based guideline. BMC med. 2020;18(1):72. PMID: 32204714 DOI: 10.1186/s12916-020-01516-x
15. Alsamarai S, Adams JM, Murphy MK, Post MD, Hayden DL, Hall JE,et al. Criteria for polycystic ovarian morphology in polycystic ovary syndrome as a function of age. J Clin Endocrinol Metab. 2009;94(12):4961-70. PMID: 19846740 DOI: 10.1210/jc.2009-0839
16. Farhadi-Azar M, Behboudi-Gandevani S, Rahmati M, Mahboobifard F, Khalili Pouya E, Ramezani Tehrani F, et al. The prevalence of polycystic ovary syndrome, its phenotypes and cardio-metabolic features in a community sample of Iranian population: Tehran lipid and glucose study. Front End. 2022;13:825528. PMID: 35299965 DOI: 10.3389/fendo.2022.825528
17. Zakeri A, Ebadinejad A, Rahmati M, Momenan AA, Niroomand M, Valizadeh M, et al. Body composition analysis in women with polycystic ovary syndrome: a cross-sectional study from the Tehran Lipid and Glucose Study (TLGS). BMC Endocr Disord. 2024;24(1):251. PMID: 39558339 DOI: 10.1186/s12902-024-01783-2
18. Amiri M, Hatoum S, Hopkins D, Buyalos RP, Ezeh U, Pace LA, et al. The association between obesity and polycystic ovary syndrome: an epidemiologic study of observational data. J Clin Endocrinol & Metabol. 2024;109(10):2640-57. PMID: 39078989 DOI: 10.1210/clinem/dgae488
19. Darand M, Ghorbani M, Ghadiri-Anari A, Arabi V, Hosseinzadeh M. The association between meat consumption and polycystic ovary syndrome in Iranian women: a case–control study. BMC women's health. 2025;25(1):189. PMID: 40247277 DOI: 10.1186/s12905-025-03695-2

Figure 1. Incidence of Polycystic Ovary Syndrome by Age Groups in 2019 and 2023