The Impact of Hyperthecosis on Sporting Performance of Female Players

Testosterone is an anabolic hormone that increases muscle mass and strength, stimulates erythropoiesis, promotes competitive behavior and enhances the sporting performance of female athletes. A comparative study was designed on forty female athletes who were selected from the three public and private sector universities of Lahore, they had been diagnosed with HTC by a qualified gynecologist based on clinical features and lab tests. At the same time, a healthy group of female athletes (n=40) was selected from participants of the same population and having regular menses and showed no clinical features of HTC. The main objectives of the study included: 1) to compare both the groups of female athletes on clinical features of HTC, and 2) to compare both the groups on self-perceived sports performance. Data collection was done using two different instruments involving the “Hyperthecosis Questionnaire (HTCQ)” and “Athlete’s Subjective Original Research Article Zara et al.; JPRI, 33(58B): 93-101, 2021; Article no.JPRI.78208 94 Performance Scale (ASPS)”. Data analyses involved descriptive analysis followed by an “Independent Sample t test’ to compare the physical and psychological impact of HTC and ANOVA was applied to analyze the impact of HTC on sports performance. There were significant differences between female athletes with HTC and those with Non-HTC on physical and psychological conditions. It can be concluded that female athletes with HTC were more concerned about their physical and psychological conditions. Moreover, their sporting performance was statistically significantly higher than Non-HTC athletes, which is attributed to higher energy levels caused by HTC itself.


INTRODUCTION
Hyperthecosis (HTC) is perhaps the most widely recognized endocrine issue in females of reproductive age, influencing up to 20% of individuals of this populace. It is worth mentioning that HTC is heterogeneous; normal clinical and biochemical indications of this condition incorporate hyperandrogenism, menstrual dysfunction, and polycystic ovaries. The specific reason for HTC isn't known to date. As per scientific examinations, it has all the earmarks of being a blend of three unique elements, including the genes, environmental and components like hormonal imbalance. The menstrual dysfunction directly affects the psychological and physical health of an individual [1]. The purpose of this study is to check out the impact of Hyperthecosis on the performance of female Players. Hyperthecosis directly affect the physical and psychological health of the athlete. The female athletes many time focuses on their profession rather than health. Hyperthecosis directly damage the hormonal system and fertility of females. The rationale of the study is to give knowledge about the effect of hyperthecosis and how female players face health issues and the survival of PCOS need to take notice of abnormal cysts on a primary basis. This study shows the effect of HTC on the performance of female players.

Genetics
There is evidence of a genetic component based on the existence of family clusters and twin studies have shown a two-fold increase in HTC concordance in genetically identical twins compared to non-identical twins [2].
Many other studies have suggested that there is an increased risk of HTC in young females with a family history of HTC. It is observed that many young females with low birth weight and those with a family history of diabetes or premature cardiovascular disease are at increased risk of developing HTC. Metabolic disturbances begin early in adolescence and also exist in adolescent relatives of females with HTC, even before clinical signs of HTC become apparent [3].

Environmental Factors
Regarding the origin of HTC, environmental factors such as prenatal exposure to androgens known as a male sex hormone, such as testosterone (T) and weight gain have been discussed as contributing factors [4]; therefore, genetic factors can lead to high susceptibility to HTC and the syndrome to develop only in the presence of a specific environment, most likely with exposure during fetal life or early childhood [5]. As well as clinical material from pathological conditions in humans and higher levels of T have been observed, which they were elevated to male levels found in the umbilical vein in girls born to mothers with HTC [6]. However, the only prospective study of the relationship between prenatal androgen exposure and the development of HTC during female adolescence did not confirm any association between these variables.

Biochemical and Metabolic Issues
The key biochemical irregularities of HTC incorporate hyperandrogenism, hyperinsulinemia, and ovarian brokenness. A considerable lot of the biochemical attributes of HTC worsen one another, further expanding the seriousness of the repeating condition. Treatment of HTC requires a comprehension of these interrelated biochemical issues. Biochemical hyperandrogenism is the most normally communicated component of HTC.
There might be clinical markers to distinguish hyperandrogenism in an individual, in any case, biochemical hyperandrogenism can be surveyed by an estimation of serum androgen list [7].
It has been recognized in the writing that insulin affectability is diminished in these females paying little mind to BMI and other metabolic irregularities. Hyperinsulinemia has been found to increment endogenous androgen levels, just as ovulatory brokenness and richness issues [8].

Impact of HTC on Sport Performance
The hormonal status of an athlete affects health and performance. While amenorrhea related to low energy accessibility has been displayed to diminish execution, the hormonal profile in HTC, where androgens are higher [9]. Androgens have been observed to be a necessary piece of the safeguarding of bone and muscle tissue. HTC showing endogenous androgenic profiles feature an increment in fat mass contrasted with controls without HTC, notwithstanding an expansion in slender mass. Endogenous androgens in youthful females have been less concentrated comparable to brandishing execution; notwithstanding, the predominance of competitors with HTC might reflect an advantage for sporting performance [10].

Significance
Physical activity (PA) is important for maintaining good health and promotes the maintenance of lean muscle mass, improves sleep habits, improves mental health, and helps reduce the risk of chronic diseases. Teen participation in sports can contribute to general PA needs. Additionally, there is a potential benefit of elevated androgens in female athletes when it comes to explosive power, lean mass, and cardiovascular fitness. Since HTC can be a reason for an athlete to have amenorrhea, the sports dietitian must be familiar with the clinical features and treatment modalities of HTC. Very little is known about the sports participation of female athletes with HTC considering that PA is an important part of the disease and weight control. An examination of female athletes with HTC and non-HTC may help to better understand which athletes should be most frequently screened for HTC and how characteristics of the syndrome may influence sports selection.

LITERATURE REVIEW
Current studies report the prevalence of female athletes who present with menstrual dysfunction to be higher than the general population.
Menstrual dysfunction related to HTC has been reported to be around 15%, but only a handful of studies have looked at HTC prevalence in female athletes, indicating a need for more research in this area as reported by Lebrun, [11]. Clinical health outcomes for females who are diagnosed with HTC include increased risk for infertility, dysfunctional bleeding, endometrial cancer, obesity, type 2 diabetes, dyslipidemia, hypertension, and cardiovascular disease. Given that HTC can result in many different clinical health outcomes, the proper diagnosis of HTC is essential for knowing how to manage the symptoms and mitigate the risk associated with the potential negative health and reproductive outcomes [12].
The clinical characteristics of HTC are heterogeneous among diagnosed individuals, but each represents a disturbance in reproductive, endocrine, and metabolic function. These clinical manifestations include menstrual abnormalities, hirsutism, acne, alopecia, weight gain and obesity. These females are also at risk of developing psychological problems. Long-term effects of the disease may lead to serious complications [13].

Menstrual Abnormalities
Menstrual dysfunction is one of the clinical characteristics associated with HTC and is additionally seen in over-trained or under-fueled female athletes as reported by Hosseini, [7]. Menstrual dysfunction is inconsistently defined in the literature and the prevalence of amenorrhea is reported to be 66% in female athletes [14]. In the HTC population, menstrual dysfunction is typically seen as amenorrhea, and those who are amenorrheic are typically seen as having a more severe presentation of HTC [15]. The published literature reflects that 15% of female athletes with menstrual problems were diagnosed with HTC. Limited studies to date have been published assessing female athletes with HTC, highlighting a need for further research in this population. Current evidence supports a close relationship between the degree of cycle irregularities and the grade of endocrine and metabolic disorders among these females [16].

Hirsutism
Hirsutism is the only sufficient substitute for biochemical hyperandrogenism in adolescents, as acne is common during this period and alopecia is very uncommon [17]. These physical signs are particularly noted in any clinical exam. Hirsutism is the appearance of dark, coarse hair in a male-like pattern in females, which is a very common sign of HTC, presenting in approximately 75% of young females with HTC [18]. The severity of hirsutism is visually scored using mFG, which is the current gold standard in assessment. The mFG scores body sites including upper lip, chin, and chest, upper and lower, back, upper and lower abdomen, arms, and thighs. Total scores are ranked out of and hirsutism is recognized as mild up to 15 and severe above 25 [19]. Hirsutism is an outward sign of elevated androgens.

Acne
Females presenting with acne, 39.6% of participants were diagnosed with HTC [4]. Females with resistant acne, alongside additional clinical symptoms of HTC, require further biochemical explorations to identify if a diagnosis may be present.
Alopecia is defined as the thinning of hair or scalp hair loss affecting approximately 36.6% of females with HTC [20]. In a cross-sectional study by Misso, [21] androgenic alopecia was found in 23% of patients with HTC, but this clinical finding was not tied to increased hyperandrogenism or other metabolic parameters. Genetic or environmental factors may also play a role related to hair loss in these females.

Obesity
Obesity is commonly seen in females with HTC, although not all females with HTC are obese. Obesity has been shown to contribute to HTC symptoms, and the amount of visceral fat, in particular, has been shown to play a key role [22]. Visceral adipose tissue releases several adipocytes, including adiponectin. Adiponectin has decreased expression in obesity and has been linked to insulin resistance. Adiponectin is an insulin-sensitizing, anti-inflammatory molecule [23]. A meta-analysis in 2014 noted lower total adiponectin levels in HTC females compared with normal controls, independent of BMI. Visceral fat likely contributes largely to insulin resistance, which leads to the development of impaired glucose tolerance and type 2 diabetes. The conversion rate of insulin resistance to diabetes is estimated to range from 2.5% to 3.6% annually throughout 3 to 8 years [23].

Psychological Effects
Females with HTC are more prone to have depression, anxiety, low self-esteem, a negative body image and psychosexual dysfunction. There are concerns with feminine identity and body image, largely thought to be attributed to increased prevalence of obesity, acne, excessive male-pattern hair, infertility, and long-term health consequences [24]. These are thought to lead to poor body image, and mood disturbances as reported by Bazarganipour, [25] who evaluated the symptoms of depression, anxiety, and perceived stress in females reporting HTC and females without HTC. The findings indicated that even after adjusting for BMI, infertility diagnosis, sociodemographic factors, females with HTC were still more likely to be depressed, anxious and have a higher level of perceived stress [26].

METHODOLOGY
The comparative study was designed and conducted in which a sample of female athletes (n=40) who had been diagnosed with HTC by a qualified gynecologist based on clinical features and lab tests. At the same time, a healthy group of female athletes (n=40) was selected from participants of the same population and having regular menses and showed no clinical features of HTC. Data was collected from The University of Punjab, The University of Lahore, and The University of Lahore College for Women. Data collection was done using two different instruments involving the "Hyperthecosis Questionnaire (HTCQ)" and the "Athlete's Subjective Performance Scale (ASPS)". Data analyses involved descriptive analysis followed by an "Independent Sample t test' to compare the physical and psychological impact of HTC and ANOVA was applied to analyze the impact of HTC on sports performance. The researcher used Analysis of variance (ANOVA) is a statistical technique that is used to check if the means of two or more groups are significantly different from each other, Anova was used to compare HTC and Non-Htc players' performance.

Dependent Variable
Athlete's Subjective Performance Scale (ASPS) by Jenna C. Gibbs used to measure players performance.

DISCUSSION
The findings of this study indicated a significant effect of HTC on sporting performance. A few studies had shown that T levels in the blood may not accurately predict enhanced sports performance in female athletes showing levels within the normal female range, there are grounds to claim that very high levels of blood T increase sporting performance in females with androgen sensitivity [27].
The hormonal status of an athlete impacts health and performance. 89the hormonal profile in HTC where androgens are higher may show improved sporting performance. Androgens are integral in the preservation of bone and muscle tissue [28]. While it represents pharmacological intervention, research on exogenous androgenic-anabolic steroid use shows improvement in sporting performance through decreased fatigue, increased power and lean body mass [29]. Skeletal muscle is highly responsive to T level, and aids in increases of skeletal muscle mass, which can in turn increase power performance and affect body composition on T level indicated that supplementation benefited body composition in men by increasing lean mass and decreasing fat mass [30]. Body composition data on the female with HTC who exhibit endogenous androgenic profiles highlights an increase in fat mass compared to non-HTC controls, in addition to an increase in lean mass. Endogenous androgens in females have been less studied related to sporting performance; however, the prevalence of female athletes with HTC may reflect an advantage to sporting performance [31].
Naturally present androgen metabolites and precursors, such as T levels, Androstenediol and Etiocholanolone glucuronide, have all been associated with performance outcomes in female athletes. Arngrímsson et al. [32] revealed that there is a positive correlation involving the presence of increased T level and explosive performance in female athletes. Similarly, serum was strongly linked to both explosive power and lean mass-two critical components of sporting performance in female athletes. Abasian et al. [33] found higher maximal oxygen uptake (VO2 max) exhibited in hyperandrogenism or amenorrhea athletes compared to non-HTC athletes. These findings suggest athletes with HTC potentially being at a competitive strength advantage; however, more research is needed.
Female athletes are more likely to have higher T levels, which should be taken into consideration by sporting regulations, according to new research. According to the findings of a few studies, researchers show that top female athletes are more likely to have higher T levels and mild disorders, as well as more severe and rarer conditions that increase T levels [34]. These findings suggest that higher T levels can enhance sporting performance in females, to levels more comparable to male physiology, and raises questions on how to ensure fairness of competition in female athletes [35].
Athletes must have separate male and female events to maintain the fair game, as men naturally have physical advantages in strength, speed, and endurance. These characteristics are widely accepted to be due to men having 15-to 20-fold greater levels of T than children or females at any age [36]. Recent regulations introduced by the International Association of Athletics Federation (2020) and the International Olympic Committee (2019) on the management of naturally high T levels in female athletes have been controversial. The new regulations require females with high levels to medically reduce them to be allowed to compete, however, the fairness and morality of these rules have been challenged by human rights and academic experts.

CONCLUSION
Based on the results, it can be concluded that female athletes with HTC were more concerned about their physical and psychological conditions. Moreover, their sporting performance was statistically significantly higher than Non-HTC athletes, which is attributed to higher energy levels caused by HTC itself. Future research must focus on measuring the energy level of female athletes with HTC and Non-HTC to confirm that the higher energy level among female athletes is due to naturally occurring T levels. Hence study has proven that HTC directly affects the health of female players and HTC group performance is higher as compared to non-HTC athletes.

CONSENT
As per international standard or university standard, respondents' written consent has been collected and preserved by the author(s).

ETHICAL APPROVAL
It is not applicable.