TNF and hyperinsulinism: The pathology mechanisms of PCOS is a vicious circle of hyperandrogenism facilitating abdominal visceral adiposity which aggravates androgen secretion of ovarian and/or adrenal origin by the direct modulation of cytokines such as tumor necrosis factor, interleukin 6, and leptin or the indirect induction of insulin resistance and hyperinsulinism (34).