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PCOS

Dr.Nagamani has published extensively in the area of PCOS and is internationally recognized as an expert in treatment of

 women with PCOS and Hyperthecosis of the ovaries (severe form of PCOS). 

 

Polycystic Ovarian Syndrome and Infertility

One of the most common causes for female infertility is Polycystic Ovarian Syndrome (PCOS), a disorder that affects between 5% and 12% of the women of reproductive age. PCOS causes a woman’s ovaries to become enlarged and develop a number of small cysts inside. Because women with PCOS rarely ovulate (release eggs), they have very irregular periods and cannot conceive.

Hormone imbalances in PCOS

PCOS is associated with a number of hormone imbalances. For example, women with PCOS usually produce too little progesterone and too much estrogen (two key female hormones). As a result, some only get a “period” every 2 to 4 months, and others go even longer without bleeding at all. In between periods, the lining of the uterus continues to build up and thicken so when it finally sheds, the bleeding can be heavy.

Women with PCOS also produce too much androgen – a male hormone – which causes “masculine” symptoms such as course hair growing on the face, chest, back, abdomen and inner thighs. Androgens can also cause the skin to get oily and develop acne. In addition, women with PCOS don’t respond normally to insulin, a hormone that regulates blood sugar. In response, their bodies produce extra insulin, which may cause the ovaries to produce more male hormones and make their symptoms even worse.

PCOS and Obesity

PCOS is closely associated with obesity. Majority of women with PCOS are significantly overweight. Obesity contributes to the hormone imbalances of PCOS, worsening irregular bleeding and unwanted hair growth. Left untreated, PCOS can lead to serious health problems like diabetes and heart disease. About 40% of women develop diabetes by age 40 if untreated.

The cysts that appear in PCOS can be detected by ultrasound. They usually remain small, do not require surgical removal, and do not lead tp ovarian cancer. And perhaps the best news of all is that for many obese women with PCOS, just losing 5% to 10% of their body weight will allow them to resume normal, regular ovulation. Weight reduction is also associated with reduced levels of androgen, improved response to insulin, better cholesterol levels, lowered risk for heart disease and possibly prevent development of diabetes.

Treatments

When weight loss alone will not bring on ovulation, ovulation must be induced medically. A number of different medications and approaches are available. Before choosing a treatment, it is necessary rule out other possible reasons for infertility such as problems with the uterus or fallopian tubes, hormone problems besides PCOS, or problems with the partner’s sperm.

Clomiphene

Once these possibilities are eliminated, first line of treatment is with a fertility pill called clomiphene citrate (CC) to induce ovulation. Approximately 80% of women with PCOS are able to ovulate when treated with CC, although the response rate is somewhat lower in obese women.

Generally, clomiphene citrate has few or mild side effects, including hot flashes, upset stomach or bowels, headaches, sensitivity to bright light, visual disturbances, mood swings, and breast tenderness. Clomiphene citrate may also result in multiple pregnancy (5 to 10 percent of pregnancies will be twins). According to some studies, prolonged use of clomiphene citrate may increase the risk of ovarian cancer.

Women taking clomiphene have to monitor their monthly cycle closely to determine whether the treatment is working. Patients track their temperature every morning with a specially sensitive thermometer (known as a “basal body thermometer”) that can detect the slight rise in temperature that occurs after ovulation. Ovulation can also be confirmed through ultrasounds or blood tests.

Gonadotropins

Women who don’t respond to clomiphene are often treated with a type of injectable medication called a gonadotropin. Gonadotropins contain either FSH alone or FSH plus LH, two hormones from the pituitary gland that induce ovulation. Women taking gonadotropins sometimes release more than 1 egg in a given cycle, which can lead to multiple births of triplets or more. Women receiving gonadotropins need to be closely monitor to avoid multiple births. If the risk for multiples is too high, treatment is usually stopped for that cycle.

Women with PCOS must also be monitored for a serious medical condition known as ovarian hyperstimulation syndrome (OHSS). When medication causes a large number of eggs to develop, the ovaries can enlarge and leak fluid into the abdomen. This can create severe pelvic pain, sudden weight gain, nausea, and vomiting. Severe cases of OHSS can lead to more serious complications that require hospitalization.

Another approach to treating PCOS involves minor surgery known as ovarian cautery. Androgen, the male hormone, is released from the center of the ovary. Destroying a small portion of the ovary with an electrical current (a procedure called “cautery”) often reduces androgen production. Ovarian cautery is carried out under general anesthesia and done by laparoscopy (guiding a needle through a very small cut near the navel). The needle punctures the ovary and delivers enough electrical current to destroy a bit of tissue. Ovarian cautery carries a risk of creating scar tissue on the ovary and it is often successful at lowering androgen and allowing women to ovulate only for short period after the surgery.

If these treatments fail, there is still another option: In Vitro Fertilization (IVF). In IVF, eggs are removed from a woman’s ovaries, fertilized with her partner’s sperm in a laboratory, and then returned to her uterus to develop into a baby. Various drugs are used to help create and maintain the pregnancy.

Treatment of Insulin Resistance

PCOS is a serious disorder that poses long-term health risks of diabetes and heart disease. But proper diagnosis and treatment of PCOS – including healthy lifestyle changes - can greatly improve a woman’s health, her symptoms, and her chances for having a baby.

Hyperthecosis of the ovaries

Some women with PCOS if untreated develop hyperthecosis of the ovaries. The clinical features of hyperthecosis are similar to those of PCOS. However, women with hyperthecosis have more hirsutism and are much more likely to be virilized. Most women with ovarian hyperthecosis are obese and have a long-standing history of hirsutism. The hirsutism is usually severe, and most of the women shave daily. Many also have clitoral enlargement, temporal balding, deepening of the voice and a male habitus. Most have amenorrhea, and the remainder have irregular and anovulatory cycles. Some have acanthosis nigricans, suggestive of severe insulin resistance. A familial occurrence of hyperthecosis has been reported, with the mode of inheritance being consistent with an autosomal dominant pattern. Women with hyperthecosis have severe insulin resistance and do not ovulate with clomiphene treatment.