PCOD was discovered by and named as STEIN LEVENTHAL SYNDROME.PCOD is a heterogeneous , multisystem endocraniopathy in women of reproductive age group with the ovarian expression of various metabolic disturbances and a wide spectrum of clinical features.
Current incidence of PCOS 5-6% is fast increasing lately due to change in lifestyle and stress among on fertile women, about 20%infertility is attributed to anovulation caused by PCOD. Some of women who develop cardiovascular disease, hypertension, and endometrial cancer and type 2 diabetes later in life appear to have suffered from PCOD in earlier years.
AETIOLOGY AND PATHOGENSIS:
- change in Life style
- genetic and environmental factors
- insulin resistance
- obesity(BMI>30 kg/m2)(waist line>88cm)
Patients suffering from polycystic ovarian disease (PCOD) have multiple small cysts in their ovaries (the word poly means many). These cysts occur when the regular changes of a normal menstrual cycle are disrupted. The ovary is enlarged; and produces excessive amounts of androgen and estrogenic hormones. This excess, along with the absence of ovulation, may cause infertility.
We don’t really understand what causes PCOD, though we do know that it has a significant hereditary component, and is often transmitted from mother to daughter. We also know that the characteristic polycystic ovary emerges when a state of anovulation persists for a length of time. Patients with PCO have persistently elevated levels of androgens and estrogens, which set up a vicious cycle. Obesity can aggravate PCOD because fatty tissues are hormonally active and they produce estrogen which disrupts ovulation . Overactive adrenal glands can also produce excess androgens, and these may also contribute to PCOD. These women also have insulin resistance ( high levels of insulin in their blood, because their cells do not respond normally to insulin).
Polycystic Ovarian Syndrome can be easy to diagnose in some patients. The typical medical history is that of irregular menstrual cycles, which are unpredictable and can be very heavy; and the need to take hormonal tablets (progestins) to induce a period. Patients suffering from PCOD are often obese and may have hirsutism , (excessive facial and body hair) as a result of the high androgen levels. However, remember that not all patients with PCOD will have all or any of these symptoms.
This diagnosis can be confirmed by ultrasound, which shows that both the ovaries are enlarged; the bright central stroma is increased; and there are multiple small cysts in the ovaries. These cysts are usually arranged in the form of a necklace along the periphery of the ovary.
Blood tests are also very useful for making the diagnosis. Typically, blood sugars and blood levels of hormones reveal a high LH (luteinising hormone) level; and a normal FSH level (follicle stimulating hormone) (this is called a reversal of the LH : FSH ratio, which is normally 1:1); and elevated levels of androgens ( a high dehydroepiandrosterone sulphate ( DHEA-S) level) ;
While some women with PCOD will have all the classic symptoms and signs, many have what we call “occult PCOD”. This means that they may be thin, have regular periods, no hirsutism and normal looking ovaries on ultrasound, but still have PCOD. This problem is detected only when these patients are super ovulated, at which time they over-respond by producing a large number of follicles.
Interestingly, many of these patients present with recurrent pregnancy loss ( recurrent miscarriages).
Treatment of PCOD for the infertile patient will usually focus on inducing ovulation to help them conceive.
For many patients with PCOD, weight loss is an effective treatment – but of course, this is easier said than done! Crash diets are usually not effective.
Increasing physical activity is an important step in losing weight. Aerobic activities such as walking, jogging or swimming are advised.
How can ovulation be induced in patients with PCOD?
The drug of first choice for women with PCOD today is metformin (this medicine is also used for treating patients with diabetes.PCOD also have insulin resistance – a condition similar to that found in diabetics, in that they have raised levels of insulin in their blood ( hyperinsulinemia) , and their response to insulin is blunted. This is why some patients with PCOD who do not respond to clomiphene are treated with antidiabetic drugs, such as metformin and troglitazone.
Clomiphene resistant PCO women may need ovulation induction with HMG (gonadotropins). Some doctors prefer to use pure FSH for inducing ovulation in PCOD patients because they have abnormally high levels of LH.
Ovulation induction can often be difficult in patients with PCOD , since there is the risk that the patient may over-respond to the drugs, and produce too many follicles, which is why the risk of ovarian hyper stimulation syndrome (OHSS) and multiple pregnancy is often increased in patients with PCOD.
Difficult patients may also need a combination of a GnRH analog (to stop the abnormal release of FSH and LH from the pituitary) and HMG to induce ovulation successfully.
A recent treatment option uses laparoscopy to treat patients with PCOD. During operative laparoscopy, a laser or cautery is used to drill multiple holes through the thickened ovarian capsule. This procedure is called laparoscopic ovarian cauterization or ovarian drilling or LEOS ( laparoscopic electrocauterisation of ovarian stroma) . This should be reserved for women with PCOD who have large ovaries with increased stroma on ultrasound scanning. Destroying the abnormal ovarian tissue helps to restore normal ovarian function and helps to induce ovulation. For young patients with PCO ovaries on ultrasound, if clomiphene fails to achieve a pregnancy in 4 months time, we usually advise laparoscopic surgery as the next treatment option. This is because LEOS helps us to correct the underlying problem; and about 80% of patients will have regular cycles after undergoing this surgery, of which 50% will conceive in a year’s time, without having to take further medication or treatment.
The skill of the surgeon plays a key role in determining the outcome of the surgery . It is important that the surgeon selectively destroy only the stroma, and NOT the cortex. The cortex of the ovary contains the eggs, and if this damaged, then ovarian function is jeopardized, so that the surgery may actually end up causing infertility.
For patients who do not respond to the above measures, ovulation induction plus intrauterine insemination is the next step.
The good news is that with the currently available treatment options, successful treatment of the infertility is usually possible in the majority of patients with PCOD.