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Small
Breast ||
Female
Hormone Deficiency || Unwanted
Hair || Milk
Secretion
Early Breast
Development || Menstrual
Irregularity ||
Infertility
|| PCOD
Excess
Menstrual Bleeding ||
Premature
Ovarian Failure || Premenstrual
Syndrome
Menopause
|| Hormone
Replacement Therapy
PCOD
Infertility in Female
Premenstrual
Syndrome
Excess
Menstrual Bleeding
Poly-Cystic Ovarian Disease (PCOD)
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What is Pcod
Why This Occurs
Investigation& Diagnostic Tests:
Treatment
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Introduction: The full form of PCOD is polycystic ovarian disease. In this disease when ultrasound of ovary is done it is studded with multiple small cyst that is why this disease is called polycystic disease.
Before discussing other detail about PCOD, I'll like to let you know about what is the normal physiology of menstruation. In normal female there are lacs of immature egg (ovarian) follicle lying in dormant state in the ovary. During the normal menstrual cycle on third day of cycle approximately 30 egg follicles starts maturing finally one of them
will mature to full stage to form mature egg. When all the hormones are normal then one out of all maturing egg follicle is selected for further maturation & rest all shrink & atrophy. Finally this selected eg follicle passes through various stages of development & finally matures into a completely developed egg called ovum. Then egg is released out of the ovary (i.e. ovulation). Once the ovum is released ovary starts secreting progesterone for next 10 days. This progesterone hormone leads to strengthening of walls of blood vessel of endometrium. After 10 days of egg release i.e. ovulation, the production of progesterone hormone from ovary ceases. Thus the sudden deficiency of progesterone hormone leads to weakening of the linings of endometrial blood vessels which ultimately shrink & stop supplying blood to endometrium i.e. inner uterine lining. Thus in nut shell the production of estrogen from ovary lads to formation of inner lining of the uterus during menstrual cycle, where as production of progesterone from ovary after the ovulation leads to maintenance of this uterine lining. The menstrual bleeding occurs due to shedding of uterine inner lining i.e. endometrium due to disruption of its blood supply because of sudden deficiency of progesterone because of stoppage of its production from ovary. Thus if no ovulation occurs, there will not be any cyclical exposure of progesterone resulting in absence of regular menstrual bleeding.
The full form of PCOD is polycystic ovarian disease. In this disease when ultrasound of ovary is done it is studded with multiple small cyst that is why this disease is called polycystic disease. These cysts are not real cyst but they are immature egg follicle. These multiple partially developed eggs looks like multiple cyst.
WHY THIS OCCURS
In this disease there is formation of more than normal amount of male hormones as testosterone & Androstenidione from the ovary in that patients due to various causes mentioned below. For your information normally also ovary makes some amount of male hormone even in normal females. But in this disease the amount of secretion of male hormone increases due to various defects as absence of ovulation, appearances of hair growth over face.. The various causes of this excess male hormone formation from ovary is as follows.
1) PRIMARY PCOD: In this the ovary has inherent defect in structure & functions due to its defective development since birth so that it start making little more male hormone (testosterone & Androstenidione) than normal females. This little extra male hormone suppresses the maturation of egg in ovary. Thus multiple immature egg are present in ovary in every cycle (these immature look like cyst on ultrasound, but in real sense they are not cyst) but none of the immature follicle completes the maturity to fully developed eggs. Thus ovulation does not take place. Once there is no ovulation that leads to deficiency of progesterone hormone resulting into absent periods.
2) Secondary PCOD: When all the classical features occurs due to obesity, congenital adrenal hyperplasia, Hypothyroidism, hyper-prolactinemia, etc.
Investigation& Diagnostic Tests:
Following tests will be required to diagnose the cause of pcod / Pcos, & to decide whether it is primary or secondary & what is its severity.
Complete hormone profile: LH, FSH, total testosterone, free testosterone, Androstenidione, SHBG, 17 HYDROXYPROGESTERONE, DHEAS, Estradiol, DH Suppression & Stimulation Tests,
High Resolution Ultrasound
Color Flow Doppler
MRI
CT abdomen
TREATMENT
Treatment includes suppression of male hormone production & suppression of male hormone action at hair root levels.
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1.) For Unwanted Facial Hair: |
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a.) Cyproterone Acetate
b.) Ethinostriadol
c.) Finasteride
d.) Dutasteride
e.) Ketoconazole
f.) Flutamide
g.) Cimetidine
h.) Cyproheptadine
i.) GLUCOCORTICOID
j.) Combined o. c. pills
k.) LASER TREATMENT: Permanent cure for the facial hair is LASER
TREATMENT at good laser centre.
l.) I.P.L.
m.) ELOS
n.) DOUBLE SQUARE PULSE THERAPY
o.) IPULSE
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2.) For Late Periods: To bring normal periods
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a) Medroxyprogesterone
b) Desgestrol
c) Megestrol
d) Norethisterone
e) Hydroxyprogesterone
f) Metformin
g) Glitazones
h) Oral E & P Combination Pills
i) Weight Reduction
j) Regular Isometric Exercises
k) Other Newer Treatments
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a) Clomiphene
b) Gonadotropin Therapy
c) HCG Therapy
d) Hmg therapy
e) Metformin
f) Glitazones
g) Laser Ovulation Induction
h) Tamoxifene
i) Letrozole
j) Diathermy of Ovaries |
2). Excess bleeding during period may also occur due to obesity, congenital adrenal hyperplasia, Hypothyroidism, hyperprolactinemia, hyperthyroidism & many other hormone diseases as DUB, Clotting disorder etc. For treatment all above causes are investigated then treated accordingly.
3) Premenstrual syndrome
occurs due to some hormone disorder & fluid retention in which patient get depressed, anxiety, body pain, fullness & bloating of body, Swelling over body. These symptoms are more pronounced before, during & after the periods. There are certain medicines which can cure it in few month time. The medicines are
a) Medroxyprogesterone
b) Desgestrol
c) Megestrol
d) Norethisterone
e) Hydroxyprogesterone
e) Oral E & P Combination Pills
2) Infertility In Female
Infertility is defined as inability to conceive in a couple having unprotected intercourse for over one year. Difficulty in conceiving & inability to have child in female can be due to many of below mentioned hormone diseases & other causes as discussed below.
Causes of Infertility
common causes for infertility are
- Male Factor infertility
- Female Factor infertility
- infertility due to minor defects in both couple
Causes of Female Factor infertility:
Hormone Disorder: thyroid hormone disorder, high prolactin, Estradioal deficiency LH, FSH deficiency, Polycystic ovarian disease (PCOD), defective egg formation, decrease in progesterone hormone, Hypothalmic & pituitary disorder, excess of various male, Hyperprolactinemia, Anavulation/oligoanovulation, Chronic anovulation (polycystic ovary syndrome), Hypothalmic amenorrhea-anovulation, Pituitary disease (including hyperprolactinemia), Adrenal disease, Thyroid disease, Luteinized unruptured follicle syndrome, Ovarian failure, Gonadal dysgenesis
hormone in female.
Vaginal Causes : Excessive acidity, chronic vaginitis
Cervical Causes : Hormonal, Inadequate estrogen, Infection : Chalmydia trachomatis, Ureaplasma
urealyticum, Anatomic : Destruction by cone biopsy or cauterization, Immunologic.
Uterine causes : Leiomyomas, Polyps, Intracterine synechiaq (Asherman syndrome), Chronic endometritis, Ureaplasms urealyticum, tuberculosis.
Tubal Causes : Infectious, Chlamydia trachomatis, Neissaria gonorrhoeae, Mycobacterium tuberculosis, streptococcus, anaerobes, Inflammatory salpingitis isthmica nodosa.
Congenital Abnormalities : Diethylsitilbestrol exposure, idiopathic.
Endometriosis: Mild, Moderate, Severe
Ovulatory Disorders : Luteal phase deficiency, Hypoprogesteronemia, Pelvic Adhesions : After intrauterine device use, Associated with pelvic inflammatory disease, Associated with appendicitis, Associated with other bowel disease, Idiopathic
Immunological disorders - eg. SLE.
Infections eg TORCH infections.
Metabolic Diseases : Diabetes
Investigations & Diagnosis : We need detailed history examination , blood tests as LH, FSH, Prolactin, Thyroid test, testosterone, free testosterone, androstenidione,17-hydroxyprogesterone, Dheas, SHBG, .
Antisperm antibodyn sometimes also required to know the cause of infertility in females.
TORCH IgM for infection screening
USG for follicular/ Ovulation study, hysterosalpingography for uterus & tube status & Laproscopy
Transvaginal follicular monitoring with color Doppler for egg development
Hysteroscopy for diagnosos & treatment of uterine cavity diseases.
Treatment: . After a diagnosis of infertility, the best treatment plan based on the specific requirement is selected. Many times a combination of fertility treatments is necessary to achieve pregnancy. Commonly recommended treatments include ovulation induction, injectable ovulation induction, intrauterine insemination (IUI), in vitro fertilization (IVF) and reproductive surgery. By correction of these disorders good egg formation occurs & leads to conception in three to six months time.
1) Drugs For Infertility
a) Clomiphene
b) Gonadotropin Therapy
c) HCG Therapy
d) Hmg therapy
e) Metformin
f) Glitazones
g) Micronized progesterones
h) Laser Ovulation Induction
i) Tamoxifene
j) Letrozole
k) Diathermy of Ovaries
Ovulation Induction
Ovulation Induction is used for patients with ovulatory dysfunction. The first line of treatment may include oral medications, such as Metrformin or Clomiphene citrate. Other diagnoses may necessitate the need for injectable medication called gonadotropins. These may include Follicle Stimulating Hormone (FSH), Leutinising Hormone (LH), human Chorionic Gonadotropin (hCG) or combination of all of these. Both types of medications stimulated the ovaries to produce one or more eggs. Frequent monitoring is usually necessary to manage the effects of the medication. Monitoring includes ultrasound of the ovaries to measure follicle growth/egg development and the thickness of the uterine lining and Hormone Blood Tests.
Super ovulation
Super ovulation is frequently used for patients with unexplained infertility; for those who had unsuccessful surgical treatment for mild endometriosis or for patients with a mild male infertility factor. In fact, super ovulation is recommended following the patient's infertility workup but before in initial laparoscopy to avoid the surgery completely. The objective of super ovulation is to stimulate the production of 2-5 oocytes (eggs), giving the sperm more 'targets' to fertile. Treatment includes Clomiphene citrate tablets or the synthetic FSH. This egg stimulation process is monitored with frequent vaginal ultrasounds and Hormone Blood testing. When the follicles (which house the eggs) are large enough, hCG is injected to trigger ovulation. Super ovulation is combined with IUI for better results.
2) Intrauterine Insemination: it is done for any defect in female vagino-cervical canal, or for a defect in male sperm count or motility. For this semen wash done & healthy motile sperms are taken & then they are injected directly in uterus leading to good pregnancy rate. IUI allows the placement of millions of sperm directly into the uterine cavity at the time of ovulation. The sperm are 'washed' with special solutions to remove the semen and to concentrate the sperm. There is a greater chance of pregnancy when the sperm are closer to the eggs with the IUI.
Therapeutic Donor Insemination (TDI)
TDI involves timed insemination from an anonymous or a known donor. It is recommended to use frozen semen to prevent genitally transmitted disease by the Food Drug Administration (FDA), USA and the Centers for
3) In Vitro Fertilization: Test tube baby procedure is adopted for various male & female causes of infertility.
4) ICSI - (Inracytoplasmic Sperm Injection): In this procedure single sperm is injected into a single eggs with the help of microinjector so that one achieves good fertilized egg & later normal baby even with single egg. The single sperm are picked and injected into the eggs using specially designed microscopes, micro needles and micromanipulation equipment. The eggs are checked then for evidence of normal fertilization. Fertilization rates for ICSI are very good. In various IVF programs the success rate foe for pregnancy are about 60-85%.
5) Gamete/Zygote Intra-fallopian Transfer
Gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT) are adaptations of IVF. GIFT and ZIFT are used in unexplained female infertility and in mild male infertility.
6) Blastocyst Transfer
7) Assisted Hatching (AH)
8) Artificial Insemination of Sperm from semen bank .This facility is not very costly with good success rate.
9) Reproductive Surgery
Surgery for fertility problems includes operative laparoscopy and/or hysteroscopy. Laparpscopy is performed to diagnose and treat endometriosis, adhesions and tubal problems. Hysteroscopic procedures are used to diagnose and treat intrauterine problems such as polyps, fibroids, adhesions and uterine septums. At times, both these surgeries may be required.
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