scholarly journals Increased micronucleus frequencies in peripheral blood lymphocytes in women with polycystic ovary syndrome

2006 ◽  
Vol 154 (4) ◽  
pp. 563-568 ◽  
Author(s):  
Elif Yesilada ◽  
Ibrahim Sahin ◽  
Hamdi Ozcan ◽  
Ibrahim Halil Yildirim ◽  
Saim Yologlu ◽  
...  
Keyword(s):  
Polycystic Ovary Syndrome ◽  
Genomic Instability ◽  
Polycystic Ovary ◽  
Peripheral Blood Lymphocytes ◽  
Sex Hormone Binding Globulin ◽  
Control Group ◽  
Total Testosterone ◽  
Ovary Syndrome ◽  
Insulin Levels ◽  
Pcos Group

Objective: We aimed to assess possible genomic instability in women with polycystic ovary syndrome (PCOS). Design: The frequency of micronuclei in cultured peripheral lymphocytes was used as a biomarker of genomic instability in somatic cells. Methods: Nineteen women, diagnosed with PCOS and 19 healthy female volunteers of corresponding ages and body-mass index (BMI) were included in the study. Micronuclei frequencies were assessed in cytokinesis-blocked lymphocytes. Results: The frequency of micronucleated cells (per thousand) was 9.00 (5.00) (interquartile range in parentheses) for patient group and 3.0 (3.0) for the control group (P < 0.0001, Mann-Whitney U-test). The serum levels of follicle-stimulating hormone (FSH), estradiol, prolactin, glucose and dehydroepiandrosterone sulfate (DHEAS) and the homeostasis model of assessment of insulin resistance (HOMA-IR) were not different between the two groups (P > 0.05). Serum total testosterone, luteinizing hormone (LH) and insulin levels and hirsutism score in the PCOS group were significantly (P = 0.007, P < 0.0001, P = 0.009 and P < 0.0001 respectively) higher than those of the control group (2.3 (2.1) nmol/l vs 1.7 (0.4) nmol/l; 8.5 (5.88) mU/ml vs 4.8 (4.4) mU/ml; 6.8 (5.1) μU/ml vs 9.7 (4.2) μU/ml; 19.5 (6.5) vs 4.0 (2.5) respectively). However, the mean level of sex hormone-binding globulin (SHBG) in PCOS group was significantly (P = 0.004) lower than in control group (36.4(22.6) nmol/l vs 48.6(25.2) nmol/l respectively). Conclusion: These findings suggest that women with PCOS have a high incidence of genomic instability, and this condition is positively correlated with the hirsutism score, BMI, LH and serum total testosterone and insulin levels, and is negatively correlated with SHBG.

scholarly journals Prevalence of metabolic syndrome in four phenotypes of PCOS and its relationship with androgenic components among Iranian women: A cross-sectional study

2020 ◽  
Author(s):  
Narges Zaeemzadeh ◽  
Shahideh Jahanian Sadatmahalleh ◽  
Saeideh Ziaei ◽  
Anoshirvan Kazemnejad ◽  
Azadeh Mottaghi ◽  
...  
Keyword(s):  
Metabolic Syndrome ◽  
Polycystic Ovary Syndrome ◽  
Polycystic Ovary ◽  
Sex Hormone Binding Globulin ◽  
Control Group ◽  
Total Testosterone ◽  
Ovary Syndrome ◽  
Significant Positive Association ◽  
Cross Sectional ◽  
Significant Difference

Background: Polycystic ovary syndrome (PCOS) increases the risk of metabolic syndrome (MetS). Insulin resistance (IR) plays a major role in the pathophysiology of both PCOS and MetS. Objective: This study was designed to compare the prevalence of MetS among different phenotypes of PCOS and its relationship with androgenic components. Materials and Methods: 182 participants eligible for this five-group comparative study were selected by convenience sampling method. They were classified according to the Rotterdam criteria: clinical and/or biochemical hyperandrogenism (H) + PCOS on ultrasound (P) + ovulation disorders (O) (n = 41), clinical and/or biochemical H + PCOS on P (n = 33), PCOS on P + O (n = 40), clinical and/or biochemical H + O (n = 37), and control (without PCOS) (n = 31). MetS was measured based on the National Cholesterol Education Program Adult Treatment Panel III criteria. Androgenic components included free androgen- index (FAI), total-testosterone (TT) level and sex-hormone-binding-globulin (SHBG). Results: A significant difference was observed between the study groups in terms of MetS prevalence (p = 0.01). In phenotype H+P+O, there was a statistically significant positive association between TG and TT, and a significant negative association between SBP and DBP with SHBG. In phenotype O+P, WC was inversely associated with SHBG. In phenotype H+O, FBS and TG were positively associated with FAI but HDL was inversely associated with FAI. Moreover, WC and DBP were positively associated with TT in phenotype H+O. No associations were detected between MetS parameters and androgenic components in other PCOS subjects (phenotype H+P) and in the control group. TT was significantly higher in the PCOS group suffering from MetS (p = 0.04). Conclusion: According to the research results, hyperandrogenic components are potent predictors of metabolic disorders. Thus, we suggest that MetS screening is required for the prevention of MetS and its related complications in PCOS women. Key words: Polycystic ovary syndrome, Metabolic syndrome, Hyperandrogenism.

scholarly journals Physical Performance Regarding Handgrip Strength in Women with Polycystic Ovary Syndrome

2020 ◽  
Vol 42 (12) ◽  
pp. 811-819
Author(s):  
Gislaine Satyko Kogure ◽  
Victor Barbosa Ribeiro ◽  
Flávia Ganoa de Oliveira Gennaro ◽  
Rui Alberto Ferriani ◽  
Cristiana Libardi Miranda-Furtado ◽  
...  
Keyword(s):  
Polycystic Ovary Syndrome ◽  
Physical Performance ◽  
Lean Mass ◽  
Polycystic Ovary ◽  
Handgrip Strength ◽  
Serum Levels ◽  
Total Testosterone ◽  
Dominant Hand ◽  
Ovary Syndrome ◽  
Pcos Group

Abstract Objective The present study aimed to investigate the physical performance of handgrip strength (HGS) in women with polycystic ovary syndrome (PCOS). Methods A case-control study that included 70 women with PCOS and 93 age-matched healthy women aged between 18 and 47 years with body mass index (BMI) between 18 Kg/m2–39.9 Kg/m2. The serum levels of total testosterone, androstenedione, insulin, estradiol, thyroid-stimulating hormone (TSH), prolactin, sex hormone-binding globulin (SHBG), and 17-hydroxyprogesterone (17-OHP) were measured. The free androgen index (FAI) and the homeostatic model assessment of insulin resistance (HOMA-IR) were calculated. The body composition regions of interest (ROIs) were assessed by dual-energy X-ray absorptiometry (DXA), and the handgrip strength (HGS) was evaluated for both the dominant and the non-dominant hands with a manual Sammons Preston (Bolingbrook, IL, US) bulb dynamometer. Results Women with PCOS had high serum levels of total testosterone (p < 0.01), androstenedione (p = 0.03), and insulin (p < 0.01), as well as high FAI (p < 0.01) and HOMA-IR (p = 0.01) scores. Compared with the non-PCOS group, the PCOS group had greater total lean mass in the dominant hand (p < 0.03) and greater HGS in both the dominant and the non-dominant hands (p < 0.01). The HGS was correlated with lean mass (p < 0.01). Conclusion Women with PCOS have greater HGS. This may be associated with age and BMI, and it may be related to lean mass. In addition, the dominance effect on muscle mass may influence the physical performance regarding HGS in women with PCOS.

scholarly journals The Relevant Hormonal Levels and Diagnostic Features of Polycystic Ovary Syndrome in Adolescents

2020 ◽  
Vol 9 (6) ◽  
pp. 1831
Author(s):  
Elena Khashchenko ◽  
Elena Uvarova ◽  
Mikhail Vysokikh ◽  
Tatyana Ivanets ◽  
Lyubov Krechetova ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Polycystic Ovary Syndrome ◽  
Diagnostic Accuracy ◽  
Polycystic Ovary ◽  
Regression Function ◽  
High Sensitivity ◽  
Sex Hormone Binding Globulin ◽  
Control Group ◽  
Ovary Syndrome ◽  
Diagnostic Features

Relevance: The clinical picture of polycystic ovary syndrome (PCOS) is extremely polymorphic, especially in adolescence. At the same time, the diagnostic criteria of PCOS in adolescence are still under discussion, and the hormonal parameters, including anti-Mullerian hormone range and hyperandrogenism, are not determined. The aim of the present study was to characterize the pivotal clinical and hormonal features of PCOS in adolescents and to establish the age-specific thresholds of the most essential hormonal parameters. Design: A case-control study. Methods: The study included 130 girls with PCOS according to the complete Rotterdam criteria, aged 15 to 17 years. The control group consisted of 30 healthy girls with a regular menstrual cycle of the same age. A complete clinical and laboratory examination, hormonal assays, and ultrasound of the pelvic organs were performed. The serums anti-Mullerian hormone (AMH), follicle-stimulating hormone (FSH), luteinizing hormone (LH), LH/FSH, prolactin, estradiol, 17α-OH progesterone (17α-OHP), androstenedione, testosterone (T), dehydroepiandrosterone sulfate (DHEAS), sex hormone-binding globulin (SHBG), leptin, and free androgen index (FAI) were analyzed. The diagnostic accuracy of AMH, FAI, LH/FSH, T, and androstenedione levels in predicting PCOS in adolescents was established using a logistic regression model and calculating area under the receiver operator characteristic (ROC) curve (AUC). Results: The serum levels of LH (9.0 (5.4–13.8) vs. 3.7 (2.5–4.7) IU/L; p < 0.0001), LH/FSH (1.6 (1.0–2.3) vs. 0.7 (0.5–1.1); p < 0.0001), 17α–OHP (4.1 (3.2–5.1) vs. 3.4 (2.7–3.8) nmol/L; p = 0.0071), cortisol (464.0 ± 147.6 vs. 284.0 ± 129.7 nmol/L; p < 0.0001), prolactin (266.0 (175.0–405.0) vs. 189.0 (142.0–269.0) mIU/L; p = 0.0141), T (1.9 (1.2–2.5) vs. 0.8 (0.7–1.1) nmol/L; p < 0.0001), androstenedione (15.8 (11.6–23.2) vs. 8.3 (6.5–10.8) ng/mL; p < 0.0001), AMH (9.5 (7.5–14.9) vs. 5.8 (3.8–6.9) ng/mL; p < 0.0001), FAI (5.5 (2.8–7.0) vs. 1.6 (1.1–2.3); p < 0.0001), SHBG (37.0 (24.7–55.5) vs. 52.9 (39.0–67.6) nmol/L; p = 0.0136), DHEAS (6.8 ± 3.2 vs. 5.1 ± 1.5 μmol/L; p = 0.0039), and leptin (38.7 ± 27.1 vs. 23.7 ± 14.0 ng/mL; p = 0.0178) were significantly altered in the PCOS patients compared to the controls. Multivariate analysis of all studied hormonal and instrumental parameters of PCOS in adolescents revealed as the most essential: AMH level > 7.20 ng/mL, FAI > 2.75, androstenedione > 11.45 ng/mL, total T > 1.15 nmol/L, LH/FSH ratio > 1.23, and the volume of each ovary > 10.70 cm3 (for each criterion sensitivity ≥ 75.0–93.0%, specificity ≥ 83.0–93.0%). The diagnostic accuracy of PCOS determination was 90.2–91.6% with the combined use of either four detected indexes, which was significantly higher than the use of each index separately. The accuracy of PCOS diagnostics reached 92% using AMH and leptin concentrations when the value of the logistic regression function [85.73 − (1.73 × AMH) − (0.12 × Leptin)] was less than 70.72. Conclusions: The results of the study estimate the threshold for AMH, FAI, androstenedione, testosterone, LH/FSH, and ovarian volume, which could be suggested for use in the PCOS diagnostics in adolescents with a high sensitivity and specificity. Moreover, the combination of either four determined indexes improved the diagnostic accuracy for the PCOS detection in adolescents.

scholarly journals Association between Luteinizing Hormone/Choriogonadotropin Receptor Ins18LQ Gene Polymorphism and Polycystic Ovary Syndrome

2020 ◽  
Vol 8 (A) ◽  
pp. 517-520
Author(s):  
Hilma Putri Lubis ◽  
Muhammad Fidel Ganis Siregar ◽  
Ichwanul Adenin ◽  
Binarwan Halim ◽  
Henry Salim Siregar ◽  
...  
Keyword(s):  
Luteinizing Hormone ◽  
Polycystic Ovary Syndrome ◽  
Gene Polymorphism ◽  
Polycystic Ovary ◽  
Control Group ◽  
Control Groups ◽  
Ovary Syndrome ◽  
Significant Difference ◽  
Pcos Group ◽  
And Control

BACKGROUND: Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders of women in the childbearing period. However, its pathophysiology is still unclear. Certain polymorphisms of the luteinizing hormone/choriogonadotropin receptor (LHCGR) genes may lead to changes in the bioactivity of this hormone. The important functional role of LHCGR in the metabolism of androgen and ovulation, the LHCGR gene variant, may be related to the risk of PCOS. AIM: The aim of this study was to evaluate the association between LHCGR Ins18LQ gene polymorphism and PCOS. METHODS: A case–control study was performed in women with PCOS and non-PCOS from May 2019 to October 2019 in HFC IVF Center. We included 50 women with PCOS and 50 healthy controls. Polymorphism of the LHCGR (ins18LQ) gene was genotyped using polymerase chain reaction-restriction fragment length polymorphism. RESULTS: From this study, we found that there was no significant difference in the proportion of ages between the groups (p > 0.05). There were significant differences in the characteristics of body mass index, FSH level, LH level, and LH/FSH ratio between the PCOS and control groups (p < 0.05). We also found that the proportion of heterozygote variant non-ins/ins was higher in the PCOS group compared to the control group, but there was no significant difference between the polymorphisms of the non-ins and non-nonins variants between the PCOS and control groups (p = 0.269). The frequency of ins alleles was higher in the PCOS group compared to the control group. CONCLUSION: There was no significant association between LHCGR ins18LQ gene polymorphism and PCOS.

scholarly journals Alarin/FSH Ratio Might Be A New Biological Marker in Polycystic Ovary Syndrome Women with Normal and Women with Obese

2019 ◽  
Vol 3 (5) ◽  
Keyword(s):  
Luteinizing Hormone ◽  
Polycystic Ovary Syndrome ◽  
Polycystic Ovary ◽  
Density Lipoprotein ◽  
Biological Marker ◽  
Dehydroepiandrosterone Sulfate ◽  
Normal Weight ◽  
Control Group ◽  
Total Testosterone ◽  
Ovary Syndrome

Neuropeptides coordinate and regulate physiological processes in all animals. Alarin is a 25 amino acid neuropeptide which promotes the secretion of luteinizing hormone (LH). It has been known that serum luteinizing hormone levels are increased in women with polycystic ovary syndrome. Therefore, purpose of this was to examine the association of circulating gonadotropin secretions, and alarin with women with polycystic ovary syndrome, and to compare these findings with those of control subjects in an effort to better understand the pathophysiology of PCOS. 28 participants with a diagnosis of PCOS with normal weight and 28 participants with a diagnosis of PCOS with obese and 28 control group participants were included in this case-control study. Hormone profiles of the participants (alarin, insulin, estradiol (E2), follicle-stimulating hormone (FSH), luteinizing hormone (LH), dehydroepiandrosterone sulfate (DHEA-SO4 ), lipid profiles total testosterone, low-density lipoprotein (LDL), high-density lipoprotein (HDL), triglyceride, cholesterol) and fasting blood sugar (FBS) values were measured. Results: Serum androgens were elevated in the PCOS. Blood LH was also elevated (P < 0.05) but was higher in PCOS than Control. Patients with PCOS had an increased alarin compared with controls. LH/FSH ratio and Alarin /FSH ratio were greater than 2.1, 2.4, respectively. The blood alarin levels were significantly correlated with the serum LH levels (r=0.492, p=0.002) and the LH/FSH ratios (r=0.450, p<0.001) and Alarin/ FSH ratios. The FSH/LH and alarin /FSH ratio were elevated in the PCOS. Based on these results, the FSH/LH and Alarin /FSH ratio appears to be a useful marker of PCOS.

scholarly journals Frequency of Polycystic Ovary Syndrome among the Students of a Medical College in Dhaka City

2020 ◽  
Vol 5 (3) ◽  
Keyword(s):  
Family History ◽  
Polycystic Ovary Syndrome ◽  
Acanthosis Nigricans ◽  
Polycystic Ovary ◽  
Total Testosterone ◽  
Dhaka City ◽  
Ovary Syndrome ◽  
Medical College ◽  
Pcos Group ◽  
History Of

Background: Polycystic ovary syndrome (PCOS) is a common heterogeneous endocrine disorder. Only few data are available in Bangladesh. The aim of this study was to find out the frequency of PCOS among the students of a medical college in Dhaka city. Materials & Methods: This cross sectional study was done among the 3rd to 5th year students of Ibrahim Medical College. We used Rotterdam criteria (Revised 2003) for diagnosis of PCOS. After taking written consent, a detailed history including menstrual history was taken. Anthropometric measurements including height in cm, weight in kg, waist circumference (WC) were measured. We assessed hyperandrogenism (H) clinically by hirsutism using a modified Ferriman-Gallway (mFG) method. The presence of acne and acanthosis nigricans was also noted. For biochemical hyperandrogenism we did total testosterone estimation. Blood samples was collected between 08.00 and 10.00 am on Days 2-7 of a spontaneous bleeding episode or randomly in the case of amenorrhea after an overnight fast. The circulating levels of total testosterone, levels were measured by Chemiluminescent Immunoassay (Advia Centaur XPTM). Transabdominal USG (Aloka F37) was done by expert radiologist of department of Radiology, BIRDEM. PCOS group was categorized in 4 different phenotypes based on the presence of oligo-anovulation (O), hyperandrogenism (H) and polycystic ovarian morphology (P) : (i) Phenotype A (O+ H+ P), (ii) Phenotype B (O+H), (iii) Phenotype C (H+P) and (iv) Phenotype D (O+P). Results: Out of 73 girls 27(37%) satisfied Rotterdam’s criteria for PCOS. Phenotype B was more common 16(59.3%) followed by A 5(18.5%) then C 3(11.1%) and D 3(11.1%). Hirsutism was found in 24 (88.8%) girls, menstrual disturbance was also present among 24 (88.8%) girls, serum testosterone was elevated in 6(22.2%) girls, 11(40.7%) had USG findings of polycystic ovaries. The mean BMI (24.70 + 3.7) was significantly high (BMI > 23 kg/ m2) among those who had PCOS (59.86%). Acne & acanthosis nigricans was observed 15(55.6%) & 6(22.2%) girls among PCOS respectively which were not statistically significant. Hypothyroidism was observed 7(25.9%) girls with PCOS. Associated family history of DM found in 21(77.8%) girls with PCOS. Family history of PCOS was present in 7(25.9%) girls in PCOS group. The difference were statistically significant (p<0.05) between two groups. Conclusion: Prevalence of PCOS is 37%, which demonstrates that PCOS is an emerging disorder. This draws attention to the issue of early diagnosis, which could provide opportunity to target the group to prevent future morbidities.

scholarly journals Lipidomics analysis of human follicular fluid form normal-weight patients with polycystic ovary syndrome: a pilot study

2021 ◽  
Vol 14 (1) ◽  
Author(s):  
Yanna Ban ◽  
Haiying Ran ◽  
Ying Chen ◽  
Li Ma
Keyword(s):  
Pilot Study ◽  
Polycystic Ovary Syndrome ◽  
Follicular Fluid ◽  
Lipid Analysis ◽  
Polycystic Ovary ◽  
Normal Weight ◽  
Control Group ◽  
Potential Candidate ◽  
Ovary Syndrome ◽  
Pcos Group

Abstract Background The polycystic ovary syndrome (PCOS) is the most common endocrine associated with insulin resistance, even in the absence of overweight. The global lipid profile of the follicular fluid in PCOS with normal weight as yet has not been investigated. The objection of this pilot study was to explore the changes of lipids in the follicular fluid of PCOS with normal weight. Methods Follicular fluid samples were collected from patients who underwent IVF, including normal-weight women without PCOS (control group, n = 10) and normal-weight women with PCOS (PCOS group, n = 8). A lipidomic analysis was performed by high performance liquid chromatography/ mass spectrometry (HPLC-MS). Multidimensional statistical analysis was performed to disclose the global differences between the two groups. Further, differential lipid analysis between the two groups was performed by Fold Change Analysis (FC Analysis) and T-test to screen potential markers. Results All 812 species of 32 subclasses of lipids were identified by lipidomics analysis. 108 kinds of lipids were considered as the potential candidate differential metabolites with the score of variable importance in the project (VIP) more than 1 by the orthogonal partial least squares discriminant analysis. 32 lipids were significantly different between the PCOS group and the control group simultaneously with FC > 1.5 or FC < 0.67, p-value < 0.05 and VIP value > 1. These differential species of lipid belong to lipid subclasses including triglycerides (TG), phosphatidylethanolamines (PE) and phosphatidylinositols (PI). Conclusion The identified differential lipids in the follicular fluid may be considered as candidate biomarkers as well as therapeutic targets of PCOS with normal-weight.

scholarly journals Aberrant activation of the Hedgehog signaling pathway in granulosa cells from patients with polycystic ovary syndrome

2020 ◽  
Author(s):  
You Li ◽  
Guohui Xiong ◽  
Jun Tan ◽  
Shudi Wang ◽  
Ziyu Zhang ◽  
...  
Keyword(s):  
Polycystic Ovary Syndrome ◽  
Signaling Pathway ◽  
Granulosa Cells ◽  
Hedgehog Signaling ◽  
Polycystic Ovary ◽  
Control Group ◽  
Hedgehog Signaling Pathway ◽  
Ovary Syndrome ◽  
Ovarian Granulosa Cells ◽  
Pcos Group

Abstract The molecular mechanism that triggers polycystic ovary syndrome is mysterious. Abnormal ovarian granulosa cells are one of the causes of PCOS. Therefore, we carried out RNA-seq in ovarian granulosa cells from patients with PCOS and normal controls and found that Hedgehog signaling pathway members Ihh and ptch2 were abnormally highly expressed in the PCOS group. Granulosa cells from 22 patients with PCOS and 21 controls with normal ovulation were collected. Subsequent qPCR tests also indicated that the expression of ptch1, gli1, and gli2 of other downstream members of Hh in the PCOS group was significantly higher than that in the control group. These results indicate that abnormally activated Hh signaling pathway, especially Ihh signal, may have a profound influence on PCOS.

scholarly journals The Correlation of Serum Total Testosterone, Sex Hormone Binding Globulin and Free Androgen Index with Athens Insomnia Scale Score in Polycystic Ovary Syndrome

2018 ◽  
Vol 10 (1) ◽  
pp. 46
Author(s):  
Hartanto Bayuaji ◽  
Heda Melinda Nazaruddin Nataprawira ◽  
Herri Suhari Sastramihardja
Keyword(s):  
Polycystic Ovary Syndrome ◽  
Sleep Disturbance ◽  
Testosterone Level ◽  
Polycystic Ovary ◽  
Sex Hormone Binding Globulin ◽  
Total Testosterone ◽  
Hormone Binding ◽  
Ovary Syndrome ◽  
Free Androgen Index ◽  
Athens Insomnia Scale

BACKGROUND: Polycystic ovary syndrome (PCOS), a common reproductive endocrinologic disorder in woman, was considered to be related to sleep disturbance. This study is aimed to analyze the correlation between excess androgen markers and Athens Insomnia Scale (AIS) in PCOS.METHODS: This observational, cross-sectional study of PCOS was conducted to 31 subjects to evaluate the correlation between serum total testosterone, sex hormone binding globulin (SHBG) and free androgen index with the incidence of sleep disturbance using AIS. Sleep disturbance was present if the score ≥6. The correlation between excess androgen markers and sleep disturbance was analyzed using Pearson’s coefficient of correlation or Spearman’s rho test. Correlation coefficient more than 0.5 with p<0.05 was considered significant.RESULTS: Out of 31 PCOS subjects aged 20-40 years, 39% subjects had AIS score ≥6. Mean serum testosterone in AIS score >6 group was higher than AIS score <6 group but not statistically significant (46.68 vs. 28.49 ng/mL, p>0.05). No significant correlation was found between serum total testosterone, SHBG and free androgen index with AIS score. After adjusting for AIS score, there was the moderate positive correlation between serum total testosterone level although not statistically significant (r=0.54, p=0.07).CONCLUSION: The serum total testosterone level might influence the occurrence of sleep disturbance in PCOS.KEYWORDS: PCOS, androgen excess, testosterone, sleep disturbance, Athens Insomnia Scale

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