Dr Girija Wagh, Obstetrician, Gynecologist, IVF expertMD, FICOG, DIP ENDO, FICS
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Multicystic or polycystic ovaries are common radiological findings with sonography and this is disturbing the psyche of the patients and doctors alike. Many young girls, women suffering with infertility or irregular cycles are seen to have this common sonographic finding. It’s heartbreaking to see young girls discussing their long time suffering from PCOS. It feels sad when these girls are labeled with a medical diagnosis at a very tender age. 25 years back when I was training for obgyn, It was extremely difficult to find such adolescent girls for my research, while today every third woman is suffering from variations of this syndrome. Any medical diagnosis causes a lot of distress and raises questions and frantic search for treatment.
This write up is an attempt to help my women friends to understand the issue, build confidence to deal with it scientifically.
Facts : Ovaries are important organs of woman’s body which releases eggs and hormones. These eggs/ovum are needed to get pregnant when fertilised with man’s sperm.
Hormones are responsible for typical feminine physical changes and functioning of the reproductive system. These almond shaped ovaries are situated deep inside woman’s body and are vital in the menstrual function.
Menstrual cycle is a normal function of woman’s body. It’s regulated by important hormones, secreted by the pituitary, hypothalamus (situated in brain) and ovaries.
There is a complete internal, cyclical pattern, fixed in the interactions of these hormones. Certain factors can influence the function of the ovary and cause irregular cycles.
Let take a look at commonly encountered issues here :
Cyst is a fluid filled structure, lined by a layer of tissue which is present in the ovary. These cysts are Single cysts, Functional cysts, Hemorrhagic cysts and Multiple cysts.
Single cyst is enlarge, fluid filled structure, commonly non cancerous and symptomatic (if large in size or undergo a twist). These are without any symptom and may be an incidental finding on clinical evaluation. If small in size, the doctor usually suggests expectant management and follow up for confirmation of natural resolution. Larger ones may need surgical removal and testing.
Functional cysts are usually less than 4 cm in size and commonly associated with irregular cycles. This can be due to hormonal imbalance, which is correctable and the cysts may resolve with treatment.
Hemorrhagic cyst gets diagnosed only with sonography, always. This simply means, there is blood inside the cyst, otherwise it is filled with clear fluid. This blood can be a result of little scratch on the ovary when follicle ruptures to release the ovum (ovulation). It can be a freak incident which may not repeat again and resolve on its own or with some treatment.
Hemorrhagic cysts also can be a sign of a peculiar disease named endometriosis (which I will address in my upcoming post). Rarely some tumors can have hemorrhages which needs evaluation, especially in older women. Few women have bleeding disorders and can have associated hemorrhagic cysts.
Multi cystic ovary, an Ovary which is studded by many small size cysts, usually found in teenagers and diagnosed by sonographer. It is not nice to call it a polycystic ovary, such a differentiation is necessary. Sometimes ovaries are stimulated to produce eggs in fertility treatments and this can also cause multi cystic ovaries and therefore this needs to be properly evaluated in the clinical context. Not every multi cystic ovary is polycystic and multicystic ovaries can be a part of normal physiology.
PolyCystic Ovarian Disease is a clinical entity which is characterized by irregular cycles, obesity, excessive body hair especially male type distribution (hirsutism). It is seen in lean or thin women too.
Since the disorder is a result of lifestyle change, genetic predisposition and resultant metabolic abnormalities, it was thought that the name “disease” is too stigmatizing and therefore it is considered as a ‘Syndrome’.
Doctor suspects this condition. Sonography shows a typical picture, however the diagnosis is confirmed by laboratory investigations and clinical features.
Abnormalities in fat, carbohydrate metabolism, leading to excess fat, pre-diabetic / diabetic condition are common. Other disorders such as abnormalities of the thyroid and the adrenal gland function may also coexist.
5.Why is there black pigmentation on the neck or other parts of the body with PCOD / PCOS ?
PCOD / PCOS is associated with underlying abnormality of the functioning of the insulin hormone which is called as insulin resistance. The thick black velvety pigmentation on the back of the neck, which is mistaken for grime or allergy to ornaments, is a sign of insulin resistance and tells us that we need to monitor one’s weight.
Many factors have been identified to cause this syndrome.
Asian ethnicity is a common factor where we have, inherent susceptibility to develop abnormalities in fat and carbohydrate metabolism, leading to diabetes, hypertension (high blood pressure) and obesity.
Genetic predisposition, such as diabetes or other hormonal diseases in the family are associated.
Environmental factors such as diet (predominantly carbohydrate based and devoid of micronutrients), lack of physical activity (couch potato culture) and excessive mental stress.
Other factors such as birth history (e.g. if the individual has been a premature baby or a growth restricted baby) can have a higher possibility of developing PCOD / PCOS in future. Life style changes too is adding fire to the fuel.
The hormones released from the pituitary and the hypothalamus are irregular and lack the expected feedbacks from the ovarian hormones. This happens due to the excessive androgenic hormones released from the stroma region of the ovary which is normally dormant.
Other factors such as the peripheral and visceral fat and insulin resistance, creates these abnormalities.
Thus when ovary starts forming eggs, out of which one is expected to be released, but none of the recruited eggs achieve the potential to grow to maturation and eventually to release. Thus the ovary gets studded with recruited but incomplete grown follicles which look like cysts. Such multiple cysts studding the ovary makes it look polycystic.
Yes, obesity, abnormal weight gain and polycystic changes are badly associated. Further, weight gain causes worsening of the situation. Irregular cycles, infertility (due to absence of ovulation), miscarriages (due to abnormalities in implantation of early embryo) can occur. In addition, metabolic diseases like raised blood pressure and diabetes can occur. Causion, these women are more susceptible to develop cancer of the uterine lining.
Proper evaluation of the hormonal abnormalities, irregular cycles, infertility and pregnancy losses, help guide the doctor to properly plan the treatment.
Medicines like hormonal pills (to regularize the menstrual cycles), insulin sensitizers are usually used for treatment. Dietary modifications, physical exercise are important supportive treatments and go a long way in controlling the adverse effects of this syndrome.
Some Real life examples to understand the Syndrome :
Deepa is a 18 year old girl studying 12th standard and her exams are near. She was brought for irregular cycles and excessive bleeding. Examination revealed that she is very obese with a BMI of 36 (ideal for her age is between 19-23), abdominal girth of 112 cm ( ideal is less than 88 cm ). She has history of excess weight gain in the past 2 years, as she was only reading and watching television without any physical activity; her diet was only rice-dal or rice-curry. Her protein intake was very low and had mood swings and couldn’t concentrate on studies.
After one year of corrective treatment she has improved and stabilized.
Pooja is married for 5 years and has difficulty in conceiving; no apparent cause except irregular cycles. She was obese with BMI 33. She was diagnosed a PCOD at our clinic and was treated under weight loss program.
She is now pregnant for last 8 months and is doing well.
Dr. Girija Wagh, MD (Obstetrics & Gynaecology), FICOG, FICP, Diploma (Endoscopy, Infertility), Fellowship of Indian College of Ob-Gynec, Women health care specialist, Academician, Acclaimed Orator & Researcher, B. J. Medical 1990-1992, Topper University Of Pune 1992
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