Polycystic ovarian disease by Dr.Shuchita Chattree

Polycystic Ovarian DiseaseAnd Its Homoeopathy approach

By: Dr. Shuchita chattree

M.D. (PGR)

Department of Materia Medica

Homoeopathy University, Jaipur

Email: [email protected]

111/09/14

o NORMAL OVARIESNORMAL OVARIES

Normal size 5 x 3 x 3cm

Variation in dimensions can result from.

◦Endogenous hormonal production(varies with age and menstrual

cycle)

◦Exogenous substances, including GnRH agonists, or ovulation-

inducing medication, may affect size.

OvaryOvary

4

• Several ligaments hold each ovary in position.

• The largest is called the broad ligament and is attached to the uterine tubes and uterus.

• The suspensory ligament holds the ovary at the upper end.

• The ovarian ligament is a rounded, cord-like thickening of the broad ligament.

Ovarian Attachments

5

•Ovarian surface epithelium or Germinal epithelium: Tunica albuginea.

•Ovarian Cortex: cellular connective tissue ovarian follicles corpora lutea and albicans.

•Medulla: vascular connective tissue

Ovary have 3 layer of tissues:

◦Ovarian follicles – in cortex and consist of oocytes in various stages of development. Surrounding cells nourish developing oocyte and secrete estrogens as follicle grows.

◦Mature (graafian) follicle – large, fluid-filled follicle ready to expel secondary oocyte during ovulation.

◦Corpus luteum – remnants of mature follicle after ovulationProduces progesterone, estrogens, relaxin and inhibin untill it degenerates into corpus albicans.

o Normal Female Reproductive cycle is divided into two phases:

o Ovarian phase

o Uterine phase (Menstural cycle)

Ovarian Cycle is divided into:

Menstural phase (1st-5th day)

Pre-ovulatory phase. (5th-13th days)

Ovulatory phase. (13th-18th day)

Post-ovulatory phase. (18th – 28th days)

Follicular phase

Ovalution

Luteal phase

Oocyte cellOocyte cell

Graafian follicle cell

Secondary follicle cellSecondary follicle cell

Corpus LuteumCorpus LuteumAfter ovulation, the remaining wall of the graafian follicle transforms into the corpus luteum.

The wall of the corpus luteum is folded and contains granulosa lutein cells derived from granulosa cells which secrete progesterone.

Corpus Albicans In the absence of fertilization the corpus luteum degenerates, decreases in size and form the corpus albicans which consists of dense connective tissue

● In female reproductive

cycle During follicular

phase water starts

accumulating around the

egg cell.

● Continuously size

increases as more water

accumulates.

Because of accumulation of water Follicle comes to the

periphery.

Release of ovum ovulation occurs

Remnants of the

follicle called

‘CORPUS LUTEUM’.‘CORPUS LUTEUM’.

If not fertilized,

Menstruation occurs.

● In case of ovarian cyst this collection of fluid

remain, surrounded by a very thin wall, within an

ovary.

● Any ovarian follicle that is larger than about two

centimeters is termed an ovarian cyst.

Cystic Oocyte

Rotterdam criteria defines PCO solely on total follicle no.: Presence of ≥ 12 follicles ≥ 12 follicles measuring 2-9 mm 2-9 mm in diameter and/or increased ovarian volume >10 mL>10 mL in at least one ovary.

In The 2003 Rotterdam consensus workshop concluded that:

“PCOS is a syndrome of ovarian dysfunction along with the cardinal feature of hyperandrogenism and polycystic ovary morphology.”

Very prevalent disease affecting between 6.5 and 8% of women overall.

Prevalence much higher in obese women (28% versus 5.5%).

• Originally described by Stein and Leventhal in 1935, first known as the “Stein-Leventhal syndrome”

• They saw in 7 women with amenorrhea, hirsutism, and obesity, found to have a polycystic appearance to their ovaries.

• Insulin resistance described later by Burghen (1980)

ETIOLOGIES

• No one is quite sure what causes PCOS, and it is likely to be the result of:

1)Genetic (inherited)

2)Environmental factors.

3)Metabolic disorder (IR)

Different Hypothesis:Different Hypothesis:1) Hypothalamic – pituitary abnormalities that result in

gonadotropin – releasing hormone and leutinizing hormone

dysfunction.

2) A primary enzymatic defect in ovarian or combined ovarian and

adrenal steroidogenesis.

3) A metabolic disorder characterized by

resistance in conjunction with

compensatory hyperinsulinaemia that

exert adverse effects on the

hypothalamus, pituitary, ovaries, and

possibly the adrenal glands.

PATHOGENESISPATHOGENESIS

Polycystic ovaries develop when the ovaries are stimulated to produce excessive amounts of androgens, particularly testosterone, by either one or a combination of the following (almost certainly combined with genetic susceptibility).

This occur because of:

The release of excessive LH by the anterior pituitary gland.

Through hyperinsulinaemia in women whose ovaries are sensitive to this stimulus.

Alternatively or as well, reduced levels of sex-hormone binding globulin can result in increased free androgens.

• Chronic endocrine disorder resulting in:

Insulin resistance

Hyperandrogenism

Altered gonadotropin functioning

Wickenheisser, McAllister, 2007

OVARIAN STEROID BIOSYNTHETIC

PATHWAY

Wickenheisser, McAllister, 2007

ABNORMALITIES OF PCOS OVARY

• Increase activity in chromosome CYP17 region leads to increased p450c17 enzyme and hence increased androgen synthesis.

Wickenheisser, McAllister, 2007

Decrease in chromosomal region CYP19 activity decreases aromatase enzyme activity and conversion of androgens to E2 (Estradiol) is reduced.

• This loss of aromatase and E2 biosynthesis has been proposed to involve dysregulation of signaling within the follicle leading to follicular arrest.

Wickenheisser, McAllister, 2007

hypothalamus

pituitary

ovaryovary Neg

ativ

e fe

ed b

ack

eff

ect

blo

cked

.

GnRH

LH

androgens

Androgens block inhibitory effect of progesterone

X

Abnormal Pituitary Function—Altered Negative Feedback Loop

Polycystic ovaries

•Ovulatory dysfunction:

• Amenorrhea

• Oligomenorrhea

• Irregular uterine bleeding

• Infertility

• Androgen excess:

• Hirsutism

• Seborrhea

HIRSUTISM

Male Type Hair Growth on Abdomen-PCOS

• Androgen excess:

•Acne

•Alopecia

•Virilization.

ALOPECIA

ACNE

• Insulin resistance:

• Acanthosis nigricans.

• Skin tags.

• Obesity.

Obesity

Acanthosis Acanthosis NigricansNigricans

Skin TagsSkin Tags

DIAGNOSTIC CRITERIA

RotterdamRotterdamNIHNIH

92

PCOS – Diagnostic criteria

• NIH (1990)

• Menstrual Irregularity

• Hyperandrogenism

• Exclusion of other etiologies

• Rotterdam (2003)

• 2 out of 3 required

1.Menstrual Irregularity

2.Hyperandrogenism

3.USG – Polycystic ovary

• Exclusion of other etiologies

Androgen Excess & PCOS society Criteria 2006

• Menstrual irregularity +/- USG - Polycystic ovary.

• Hyperandrogenism.

• Exclusion of other etiologies

History-taking, specifically for menstrual pattern, obesity, hirsutism, and the absence of breast development.

BBT (basal body temperature)

Diagnosis

• Ultrasonography.

• Serum (blood) levels of androgens (male hormones), including androstenedione and testosterone may be elevated.

• Serum values of Luteinizing Hormone (LH) levels or the ratio between LH : FSH is > 3 : 1

• Laproscopic view

November 9, 2014 97

PCOS – Evaluation

• Biochemical evidence of hyperandrogenism

• S. Total testosterone

• USG evidence of Polycystic ovary• 12 or more follicles in each ovary measuring 2-9 mm in

diameter +/- inc. ovarian volume (>10 mL) [Rotterdam criteria]

USG view of Normal Uterus & Ovaries.

USG view of Normal Ovary

USG view of PCOD Ovary

USG view of PCOD Ovary

PEARLY WHITEPEARLY WHITE SMOOTH ENLARGED AND THICK WALLED OVARY ON LAPROSCOPY ( PCOS)

Laparoscopy – Laparoscopy – B/L polycystic ovaries are B/L polycystic ovaries are characteristic of PCOS.characteristic of PCOS.

www.similima.com 103

DIFFERENTIAL DIAGNOSIS

• Late onset congenital adrenal hyperplasiaDHEAS (Dehydroepiandrosterone) > 18mmol/l

17 OH Prog (17 hydroxyprogestrone) > 6 mmol/l

• Ovarian + adrenal androgen secreting tumoursVery high testosterone > 6mmol/l

• Cushings Syndrome- Dexamethsone suppression test

- 24 hours urinary cortisol

- DHEAS (Dehydroepiandrosterone) > 13 mmol/l

• Iatrogenic and illegal androgen ingestion.

• Hypothyroidisms (Thyroid profile test).

• Hyperprolactinemia. (Serum Prolactine estimation)

PCOD PCOD

Psora initially Psora initially brings about brings about

functional functional changes in the changes in the form of neuro form of neuro

hormonal hormonal pathway leading pathway leading

to hormonal to hormonal changeschanges..

Sycotic miasm Sycotic miasm brings about brings about pathological pathological changes in changes in OVARIES OVARIES

leading to leading to formation of formation of

CYSTS.CYSTS.

MalignancyMalignancy

Tubercular Tubercular miasm adds miasm adds bleeding to bleeding to the CYSTthe CYST..

psora

sycosis

tubercularsyphilis

FEMALE GENITALIA - TUMORS - Ovaries – cysts:

Apis Bov. Bufo canth. carb-an. Coloc. Iod. Kali-br. Lach. merc. murx. Plat. prun. rhod. Rhus-t. thuj.

Kent Kent RepertoryRepertory

GENITALIA - Female organs – ovaries: Acon. agar. agn. Ambr. Ant-c. arn. Ars. ASAF. AUR. BELL. calc. CANTH. CARB-AN. Carb-v. caust. Chel. CHIN. clem. CON. dros. DULC. Graph. hyos. Ign. KALI-C. kali-n.

LACH. laur. LIL-T. LYC. MERC. Mez. nat-c. Nit-ac. Nux-v. pall.

PLAT. plb. puls. RAN-B. Ran-s. ruta SABIN. sars. SEC. SEP. STAPH. Sulph. THUJ. ZINC. BBCRBBCR

RepertoryRepertory

GENITALIA - Female organs - swollen – ovaries: GRAPH. LACH.

BBCRBBCRRepertoryRepertory

GENITALIA - Female organs - swollen - ovaries [double]: Apis bufo nux-m.

Female - CYSTS, genitalia - cysts, ovarian: APIS apoc. arn. ars. Aur-i. aur-m-n. aur. bell. Bov. bry.

Bufo canth. carb-an. chin. Colch. Coloc. con. ferr-i. form. graph. Iod. Kali-br. kali-fcy. Lach. lil-t. Lyc. med. merc. murx. Ov. Plat. prun. rhod. Rhus-t. sabin. sep. syc. syph. ter. THUJ. zinc.

Murphy Murphy RepertoryRepertory

Female - TUMORS, genitalia - tumors, ovaries: APIS apoc. ars-i. Ars. aur-m-n. Bar-m. bov. Calc. Coloc. con. ferr-i. fl-ac. graph. hep. Iod. Kali-br. lach. lyc. med. ov. Pall. Plat. Podo. Sec. staph. stram. syph. Thuj. zinc.

Murphy Murphy RepertoryRepertory

Pulse - FAST, pulse, elevated, exalted - ovarian cyst, in: Iod.

Murphy Murphy RepertoryRepertory

Pulse - IRRITABLE, pulse - ovarian cyst,

in: Iod.

FEMALE GENITALIA/SEX - TUMORS - Ovaries – cysts: Apis arg-met. Aur-m-n. bell. Bov. brom. Bufo canth. carb-an. carc. Coloc. foll. Iod. kali-bi. Kali-br. Lach. lyc. merc. murx. naja ov. Pall. Phos. Plat. podo. prun. rhod. Rhus-t. syc. syph. thuj.

SynthesisSynthesisRepertoryRepertory

Hedera helix (common lvy)

Female

Cystic ovaritis, especially on the left side.

Amenorrhea in young girls. Infrequent menses.

Menses late, shorter and less copious. Pre-menstrual leucorrhea.

-MURPHY R., Homeopathic Remedy Guide

Cobaltum nitricum (nitrate of cobalt):

Female:

Lack of libido. Metrorrhagia. Secondary amenorrhea.

Cystic inflammation of the ovary. Sterility

-MURPHY R., Homeopathic Remedy Guide

Chlorpromazinum (largactil)

Female: Considerable leucorrhea like egg-white. Amenorrhea. Stretch-marks. Sexual precocity. Painful menses. Cystic inflammation of the ovary.

-MURPHY R., Homeopathic Remedy Guide

Hirudo medicinalis (leech):

Female: Left-sided ovarian pain like being stabbed. Brownish leucorrhea two days before

menses. Menses: too early or late, heavy or light,

painful or less painful than usual. Feeling in the pelvis as if menses would

come on two weeks before due.

Ovarian cysts.

Nepenthes distillatoria:

Female: Stinging, needle-like, flashing pains around the right

ovary in the morning. Left ovarian pain, spreading to the left kidney. Menses

early by 5 days and copious. Menses repeat after a period of amenorrhea lasting 6

months. Feeling of swelling of whole body 10 days before

menses. Cystic ovaritis.

Ovininum: Ovary gland: (Oophorinum)

Ovary has been suggested as a remedy in ovarian cysts.

Rhododendron chrysanthum

Pain in ovaries; agg. in change of weather.

Caused rupture of cyst in right ovary.

CLARKE J. H., Dictionary of Practical Materia Medica

Robinia pseud-acacia, L

Swelling as if there were an ovarian cyst, especially in the left side of the abdomen.

ALLEN T. F., Encyclopedia of Pure Materia Medica

Argentum metallicum:

Hard, indurated, cystic ovaries, especially the left.

FARRINGTON E. A., Comparative Materia Medica (with therapeutic hints)

Murex purpurea

¤ Large cyst, supposed to be connected with left ovary, occupied space between rectum, uterus and vagina, so as to obliterate posterior cul de sac and almost occlude vagina; abdomen somewhat distended; confined to her room and bed for more than a year.

HERING C., Guiding Symptoms of our Materia Medica

The Important Common Homoeopathic drugs indicated for Ovarian cysts are:

● Bovista ● Apis mellifica ● Platina ● Lycopodium● Thuja● Lachesis

BOVISTA

Mind -Enlarged sensation. [Arg.n.] Awkward; everything falls from hands.Sensitive.

Diarrhoea before and during menses.

Menses too early and profuse; worse at night. Voluptuous sensation. Leucorrhoea acrid, thick, tough, greenish, follows menses. Soreness of pubes during menses. Metrorrhagia; Parovarian cysts.

APIS MELLIFICA

Mind -Apathy and indifference. Awkward; drops things readily. Listless; cannot think clearly. Jealous, fidgety, hard to please. Sudden shrill, piercing screams. Whining.

Tearfulness. Jealously, fright, rage, vexation, grief. Cannot concentrate mind when attempting to read or study.

Ovaritis; worse in right ovary. Menses suppressed, with cerebral and head symptoms, especially in young girls. Dysmenorrhoea, with severe ovarian pains.

Platina

Parts hypersensitive. Ovaries sensitive and burn; vaginismus,

nymphomania, pruritus vulva, ovaritis with sterility.

Menses too early, too profuse, dark clotted with spasms and painful bearing down and sensitiveness of the parts.

Mental troubles associated with suppressed menses

Self exaltation

Lycopodium

Vagina dry, painful coition. Varicose veins of pudenda. Leucorrhoea acrid with burning in

vagina. Discharge of blood from vagina during

stool. Melancholy; afraid to be alone.

THUJA

Left-sided and chilly. Mind.-Fixed ideas, Emotional sensitiveness; music

causes weeping and trembling. Female.-Vagina very sensitive. [Berb.; Kreos.;

Lyssin.] Warty excrescences on vulva and perineum. Profuse

leucorrhoea; thick, greenish. Severe pain in left ovary and left inguinal region.

Menses scanty, retarded. Polypi; Ovaritis; worse left side, at every menstrual period. Profuse perspiration before menses.

LACHESIS MUTUS (lach.)

Menses too short, too feeble; pains all relieved by the flow. [Eupion.]

Left ovary very painful and swollen, indurated. Acts especially well at beginning and close of menstruation.

Ill effects of suppressed discharges. Mind.-Great loquacity. Jealous. [Hyos.]

Mental labor best performed at night. Suspicious; nightly delusion of fire.

Bufo

Burning heat and pain in the ovaries which extends down the thigh.

Dysmenorrhoea with cysts and Dysmenorrhoea with cysts and hydatids about ovaries.hydatids about ovaries.

Iodum:

Congestion and dropsy of right ovary Congestion and dropsy of right ovary with dwindling of the mammae.with dwindling of the mammae.

Dull pressing pain extending to the uterus.

Wedge like pain in the right ovarian region.

Lilium Tig.

Ovarian neuralgia. Burning pains from ovary up into

abdomen and down into thighs. Shooting pain from left ovary

across the pubes or upto the mammary gland.

Conium Mac. Ovary enlarged, indurated, lancinating Ovary enlarged, indurated, lancinating

pain.pain. Ovaritis Breast enlarge and become painful before and

during menses. Menses delayed and scanty. Dysmenorrhoea, with drawing down thigh. Mammae lax and shrunken, hard painful to

touch. Ill effects of repressed sexual desire or

suppressed menses.

Colocynthis

Boring pain in ovary. Must draw up double, with great

restlessness. Round, small, cystic tumous in Round, small, cystic tumous in

ovaries or broad ligaments.ovaries or broad ligaments. Bearing-down cramps, causing her to

bend double.

Kali Bromatum

Ovarian neuralgia with great nervous uneasiness.

Cystic tumours of ovaries. Exaggerated sexual desire. Vomiting with intense thirst after each meal Fidgety of hands, jerking and twitching o

muscles.

Other Rare drugs indicated for Ovarian cyst

Oophorinum Aur. Iod. Xantoxylum