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POLYCYSTIC OVARIAN DISEASE (A Study of 27 cases over 5 a year period)

CH Asrani
Family Physician, Santacruz, Mumbai 400 055.

Seeing a large percentage of young women with irregular cycles, being diagnosed as PCOD, it was decided to keep data and follow them up for a 5-year period. In this study patients were assessed, investigated and treated and followed up at family practice level only. Only if deemed absolutely necessary, an opinion was taken with follow up again at domiciliary level. More than the pathology, patientís psyche had to be handled as, we shall see, the fear of being incomplete and the anticipatory anxiety of a reproductive problem cropping up in future was taking a heavier toll.

Sample statistics
All young women - 16 yr to 29 yr
No
Age group
8
16-20
11
21-25
8
26-29

 

Marital status
Unmarried
Married
9
18

 

Presenting symptoms
Irregular menstruation
Natural  
   Induced
8
1
Infertility
Primary Secondary
4
14

ASSESSMENT OF A PATIENT

1. On arrival a detailed menstrual history was taken, right from menarche to date.

In a patientís words "I had perhaps 3 or 4 periods per year at random times except when I was prescribed tablets for withdrawal bleeding and my cycles were artificially regulated for one year. When I went off the drugs the irregularity came right back".

Most patients complained of either periods of amenorrhoea or extremely irregular periods. Strangely all of them had 1-2 years of normal cycles after menarche when irregularities set in.

A detailed history of pills taken was taken and they were asked to keep a detailed record of their cycles. They were asked to mark with a red pen the days of menstrual bleeding (+ spotting; ++ normal bleeding and +++ heavy flow) (proforma enclosed)

2. A detailed history of illnesses suffered in the past, treatment taken, repeated exposure to X-rays etc is taken. 4 patients gave history of typhoid fever followed by the menstrual irregularities but detailed search of records does not give any association.

3. Male body hair patterns - Scalp hair thinning, excess/ rich growth on face (upper lip and chin) and pubic region.

4. Early development of breast buds.

5. Male fat storage patterns - Abdominal storage, rather than standard female thigh and waist storage.

6. If married, history of infertility, despite regular, unprotected intercourse as irregular ovulation reduces the odds of pregnancy each month.

7. Endocrine problems may interfere with the mechanisms of conception, implantation and the first trimester of pregnancy.

8. Mid cycle pain indicating painful ovulation - due to the enlargement and blockage of the surface of the ovaries.

Family History

1. A sister, mother or grandmother with similar symptom. May not have the diagnosis but appearance and symptoms.

6 had sisters (1 twin) with similar symptom

4 had mothers with similar symptom

3 had grand mothers with similar symptom

9 were sure they had no one with similar symptom

5 were unsure about the f/h of similar symptom

2. A father or grandfather with premature (in his 20ís) male pattern baldness

8 have father who had premature baldness

11 have brothers

? relation to PCOD

? current overall high incidence of baldness

On General Examination : The following 2 points were noted and presence is almost diagnostic with irregularity of periods.

1. Moderate to severe adult acne.

2. Early development of breasts, more for the age and/or constitution.

3. Some women also have dark velvety patches on the skin (6 out of 27).

Investigations : (to confirm or rule out)

1. FSH and LH levels with ratio - The levels of FSH and LH vary according to the stage of menstruation, but the ratio FSH-LH should always be 2. In PCOD we see a ratio of around 4 and above.

2. Pelvic Ultrasound - Ultrasound shows a honeycomb or "string of pearls" of partially developed follicles (eggs) coating the inside of the ovaries.

A combination of classical history, close observation of patient and the above investigation is enough to diagnose a case without referral to consultants.

Approach to unmarried girls/ women not desiring children

To save patients from continuous action of oestrogen, these patients are given,

Tab medroxyprogesterone 10 mg BD for 7 days in the event of not getting a natural cycle for 6 weeks from their last cycle.

They are similarly followed up till they get married and /or want to conceive.

Approach to women desiring children

These patients are given clomiphene citrate 25 mg BD for 5 days beginning 1st day of the bleeding.

Almost 70% of patients ovulate with this one course only. If husband semen is normal and other causes like blocked tubes etc are ruled out with the couple understanding the importance of dates - pregnancy is the likely outcome.

If the patient does not ovulate first cycle, next cycle 100 mg OD X 5 days is given.

If 3 cycles are not successful we wait for 3 mth. period before embarking on next cycle of treatment.

These patients after the family is complete are

treated the same way unmarried girls are treated.

A word of caution for them - since they can ovulate any time they are asked to take contraceptive precautions.

RESULTS

Primary infertility
Patients
Conceived
Delivered
Aborted
14
9
7
2
2nd cycle
5

2

2

X

From the twins 1 conceived with 1st dose of clomiphene, the other one has now accepted her status and we are counselling her for adoption.

Secondary infertility
Patients
Conceived
Delivered
Aborted
4
3
3
X
(without Clomiphene)
1

1

1

X

Unmarried girls have been assured for treatment after marriage and explained in great detail that PCOD is not a synonym for infertility. Till then they are being given protective cover of medroxyprogesterone as and when required.

DISCUSSION

Poly cystic ovarian disease (PCOD) is usually thought to be a lifetime female hormonal imbalance where maturing eggs fail to be expelled from the ovary, creating an ovary filled with immature follicles (somewhat misleadingly labeled "cysts"). The cysts then contribute to the hormonal imbalance...which causes more cysts. What causes this vicious cycle to start is not well understood, and probably varies from patient to patient: Insulin? Diet? Stress? Fat? Glandular and hormone problems?

No two women are affected by PCOD in exactly the same way.

The most common symptoms and indicators of PCO are:

1. Lack of periods, or extremely irregular periods

2. Male body hair patterns

3. Male fat storage patterns

4. Blood sugar level swings - Hyperglycaemia and/or hypoglycaemia and/or diabetes and/or insulin level problems.

5. Positive family history.

6. Reduced fertility - Irregularity of ovulation reduces the odds of pregnancy each month.

7. Adult acne

PCOD is a hormone problem defined by its symptoms: PCOD is the collection of symptoms.

They have to be taught not to panic. The stress about having the condition may contribute more to infertility than PCOD itself.

PCOD does not equal infertility. Some women with PCOD have no fertility problem at all.

In fact, a positive history in either mother or one of the grandmothers proves that fertility is possible. Many of us irresponsibly inform our non-infertility patients newly diagnosed with PCOD that they will have reproductive problems : Infertility is just another possible symptom of PCOD. Just like all of the dozen or so possible symptoms, infertility may or may not be present. Probably better than 80% of women with fertility problems caused by PCOD, properly treated and with patience, do bear a healthy child.

Getting a vaginal ultrasound will positively and quickly diagnose PCOD (as well as other conditions). Vaginal ultrasound is also the most aggressive way to track when, whether and how well a patient is ovulating, and to make sure their ovaries do not produce a dangerous number or sizeof mature eggs when taking clomiphene. Ultrasound cannot be used to absolutely rule-out PCOD because some PCOD patients do not appear to have ovarian cysts.

Surgery for PCOD : This surgery is not a permanent fix, it usually only straightens out the hormonal imbalance temporarily (perhaps one year). The downside of surgery is the risk that it could cause adhesions, which will reduce fertility until removed by another surgery, and the small risk of complete ovarian failure due to ovarian trauma.

In the west they are using metformin with significant success. It will be years before this is approved. Till then it is our responsibility to see that our next patient of PCOD does not panic and for that we have to learn not to be scared of the long name polycystic ovarian disease.



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