Polycystic Ovarian Disease in Rural Areas – includes a free patient information PDF!

What is polycystic ovarian disease and does it have any other name?

Polycystic ovarian disease is also called polycystic ovarian syndrome because the disease causes a group of symptoms and signs. It is also called Stein–Leventhal syndrome to honor those who described the disease and sometimes called hyperandrogenic anovulation to describe the syndrome.

It is one of the leading causes of infertility and causes a variety of symptoms because of the hormonal imbalances. The hallmark of the disease is the presence of multiple small cysts in the ovaries from which the name of the disease arises. There is also increase in androgens or male hormones and resistance to insulin resulting in diabetes like condition.

How common is PCOD?

The World Health Organization estimates that 3.5 percent of women all over the World have polycystic ovarian disease at any given time. While 25% of women who have ultrasound examination have the disease about 18% of women during the childbearing age have the syndrome with other symptoms. However evaluation for infertility is the most common reason for diagnosis.

What causes the disease PCOD?

There is no consensus on the cause of the disease. However there are indications that it might possibly be transmitted genetically as an autosomal dominant trait. This means that there is greater chance of occurrence in monozygotic twins rather than dizygotic twins. It also means that it occurs in families and the hormonal manifestations can be transmitted to the boys and who will have symptoms of excess androgens and insulin resistance.

The severity of the cases seems to depend on the obesity and correlates directly in that symptoms are more severe in people who are obese. Some people consider it as a metabolic disorder because of the reversal of symptoms if obesity is tackled. The hormonal changes seem to persist even if both the ovaries are removed. The hormonal changes and influences are complex.

What are the symptoms of PCOD?

The following are the symptoms of PCOD:

1. INFERTILITY: This is probably the most common presentation. The chronic anovulation or absence of release of the ovum causes infertility. The hormonal changes does not help it either
2. MENSTRUAL DISORDER: Oligomenorrhea and amenorrhea are common. These mean less periods and are due to the deficiency of female hormones. However any type of menstrual irregularity is possible
3. RESULT OF HIGH ANDROGENS: The high levels of androgen contribute to acne or pimples, hirsutism or male type of baldness, excessive body hair and facial hair, breast atrophy or small breasts, etc. Oily skin and dandruff are also common in these women.
4. METABOLIC SYNDROME: This causes so called central obesity or male type of obesity with lot of fat around the abdomen. Intestinal bloating, depression and high blood pressure are some of the features of this. Thick dark brown patches in the skin especially in the arms, legs and thighs, skin tags in the axilla and neck are also some of the features.

What are the signs to look for in PCOD?

The following are the signs to look for:

• Male pattern of hair in the chest, around the nipple, abdomen and face
• Acne and oily skin in the face, neck and back
• Thick dark skin in the armpit, thighs, etc
• Enlarged clitoris
• Small breasts
• Central obesity

What are the investigations that are available in rural areas?

Patient Handout

You can print copies of this PDF handout for your patients, to reinforce what you have told them.

The following investigations are necessary and available in rural areas:

1. Ultrasound examination reveals multiple cysts in the ovaries. If available vaginal ultrasound is better. Small ovarian follicles due to follicular arrest is an early finding
2. Blood sugars and Lipid profile are often abnormal
3. Thyroid function tests are carried out to rule out hypothyroidism that may mimic the PCOD
4. Hormone tests might not be available in rural areas. However if available the following could be carried out
   • Estrogen level
   • FSH/LH level
   • Testosterone level
   • 17 ketosteroids
   • Prolactin level
5. Sometimes diagnostic laparoscopy might be required and may be the most cost effective diagnostic method as treatment is possible at the same time.

Is there any medical treatment that is available?

The medical treatment aims to address each of the specific problems that are associated with PCOD.

1. INSULIN RESISTANCE: Metformin is the drug of choice for this. It also has the beneficial side effect of lowering the body weight. The thiazolidinedione’s [Glitazones] are used as second line treatment for those not responding to Metformin alone.
2. HORMONE IMBALANCE: The oral contraceptives are used for regulating the menstruation. They also increase the sex hormone binding globulin thus increasing the testosterone binding and reducing the effects of androgens like hirsutism
3. INCREASED ANDROGENS: Spironolactone is used for its anti – androgen effect. Eflornothine cream could be locally used for treating hirsutism. Flutamide and Finesteride or Dutasteride that are used for treating prostate disorders could be used in severe cases.
4. IRREGULAR OVULATION: Clomiphene is the most common ovulation inducer that is used. Leuprolide is another medicine that could be used.
5. METABOLIC SYNDROME: Reduction of BMI results in significant benefit. Vitamin D deficiency is also said to play a role in metabolic abnormality. Vitamin supplements and diet rich in fruits and whole grain cause significant improvement in menstrual regularity
6. TREATMENT OF ASSOCIATED DISORDERS: Associated disorders like hypertension, hypercholesterolemia etc need treatment that is usually given for them. In other words they are treated on their own merits.

What is the surgical treatment that is available in rural areas?

The surgical treatment as mentioned earlier is combined with diagnostic laparoscopy which is listed as one of the investigations. The single incision gas less laparoscopy offers the best option in rural areas. Ovarian drilling has resulted in significant number of patients with PCOD conceiving. Earlier before the days of laparoscopic surgery ovarian wedge resection was used but is not in use anymore for the fear of scar tissue damaging the ovary.

What is the prognosis and problems with PCOD?

At our surgical camps more than 20% of those treated with ovarian drilling and medical treatment have conceived.

Those with PCOD have a significantly higher risk for the following and hence need regular look out for these conditions:

1. Endometrial cancer
2. Type 2 diabetes
3. Hypertension
4. Depression
5. Cardiovascular disease
6. Stroke
7. Sleep apnea
8. Thyroid disorders
9. Ovarian and breast cancer

What are the facilities available at the SEESHA surgical camps?

The SEESHA surgical camps especially at the Bethesda Hospital in Aizawl in Mizoram offer all the possible treatment mentioned so far. The surgical treatment is available at the other places like the Karunya community hospital, ICC hospital at Coimbatore, the Sielmat hospital at Churachandpur and Family health clinic at Dimpur and at the other places.

Laparoscopic surgery is carried out through the most modern and safe procedure of single incision gas less laparoscopic surgery. With only a small incision at the level of the Umbilicus there is hardly any scar tissue visible. It can be carried out in rural areas with spinal anesthesia.