Polycystic ovarian disease by Dr.Shuchita chattree

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Polycystic Ovarian DiseaseAnd Its Homoeopathy
approach

• By Dr. Shuchita chattree
• M.D. (PGR)
• Department of Materia Medica
• Homoeopathy University, Jaipur
• Email shuchita.chattree_at_gmail.com

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NORMAL 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.

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Ovary
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Ovarian Attachments

• 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.

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Histology
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Ovary have 3 layer of tissues

• Ovarian surface epithelium or Germinal
  epithelium Tunica albuginea.
• Ovarian Cortex cellular connective tissue
  ovarian follicles corpora lutea and albicans.
• Medulla vascular connective tissue

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Cortex have following stage of developement
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• 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
  ovulation
• Produces progesterone, estrogens, relaxin and
  inhibin untill it degenerates into corpus
  albicans.

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• Normal Female Reproductive cycle is divided into
  two phases
• Ovarian phase
• Uterine phase (Menstural cycle)

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• 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
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Histological appearance Of ovary tissues
during Female Reproductive cycle
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As we Magnifying it we sees
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Oocyte cell
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Graafian follicle cell
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Secondary follicle cell
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Corpus Luteum

• After 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.

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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

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How does cyst form???
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• In female reproductive cycle During follicular
  phase water starts accumulating around the egg
  cell.

• Continuously size
• increases as more water
• accumulates.

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Because of accumulation of water Follicle comes
to the periphery.
Release of ovum ovulation occurs
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Remnants of the follicle called CORPUS LUTEUM.
If not fertilized, Menstruation occurs.
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• 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.

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Cystic Oocyte
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Polycystic Ovaries

• Rotterdam criteria defines PCO solely on total
  follicle no.
• Presence of 12 follicles measuring 2-9 mm in
  diameter
• and/or increased ovarian volume gt10 mL in at
  least one
• ovary.

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• 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.
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• Epidemiology

• Very prevalent disease affecting between 6.5 and
  8 of women overall.
• Prevalence much higher in obese women (28 versus
  5.5).

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History

• 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)

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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)

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Pathophysiology
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• 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.

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• 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.

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PATHOGENESIS

• 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).

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• 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.

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Polycystic Ovaries

• Chronic endocrine disorder resulting in
• Insulin resistance
• Hyperandrogenism
• Altered gonadotropin functioning

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Pathway Linking Hyperinsulinemia
Hyperandrogenemia
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OVARIAN STEROID BIOSYNTHETIC PATHWAY
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ABNORMALITIES OF PCOS OVARY
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• Increase activity in chromosome CYP17 region
  leads to increased p450c17 enzyme and hence
  increased androgen synthesis.

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Decrease in chromosomal region CYP19 activity
decreases aromatase enzyme activity and
conversion of androgens to E2 (Estradiol) is
reduced.
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• This loss of aromatase and E2 biosynthesis has
  been proposed to involve dysregulation of
  signaling within the follicle leading to
  follicular arrest.

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Hyperandrogen leads to altered Pituitary gonadal
axis.
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Normal axis
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In PCOD
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• Abnormal Pituitary FunctionAltered Negative
  Feedback Loop

hypothalamus
GnRH

Negative feed back effect blocked.
LH
pituitary
X
Androgens block inhibitory effect of progesterone
ovary
androgens
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Polycystic ovaries
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Clinical features
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• Ovulatory dysfunction
• Amenorrhea
• Oligomenorrhea
• Irregular uterine bleeding
• Infertility

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• Androgen excess
• Hirsutism
• Seborrhea

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HIRSUTISM
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Male Type Hair Growth on Abdomen-PCOS
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• Androgen excess
• Acne
• Alopecia
• Virilization.

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ALOPECIA
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ACNE
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• Insulin resistance
• Acanthosis nigricans.
• Skin tags.
• Obesity.

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Obesity
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Acanthosis Nigricans
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Skin Tags
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DIAGNOSTIC CRITERIA
Vs
NIH
Rotterdam
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PCOS Diagnostic criteria

• Rotterdam (2003)

• NIH (1990)

• Menstrual Irregularity
• Hyperandrogenism
• Exclusion of other etiologies

• 2 out of 3 required
• Menstrual Irregularity
• Hyperandrogenism
• USG Polycystic ovary
• Exclusion of other etiologies

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• Androgen Excess PCOS society Criteria 2006

• Menstrual irregularity /- USG - Polycystic
  ovary.
• Hyperandrogenism.
• Exclusion of other etiologies

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• Diagnosis

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• Diagnosis

• History-taking, specifically for menstrual
  pattern,
• obesity, hirsutism, and the absence of breast
  
• development.
• BBT (basal body temperature)

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• 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 gt
  3 1
• Laproscopic view

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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 (gt10 mL)
  Rotterdam criteria

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USG view of Normal Uterus Ovaries.
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USG view of Normal Ovary
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USG view of PCOD Ovary
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USG view of PCOD Ovary
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PEARLY WHITE SMOOTH ENLARGED AND THICK WALLED
OVARY ON LAPROSCOPY ( PCOS)
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• Laparoscopy B/L polycystic ovaries are
  characteristic of PCOS.

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DIFFERENTIAL DIAGNOSIS

• Late onset congenital adrenal hyperplasia
• DHEAS (Dehydroepiandrosterone) gt 18mmol/l
• 17 OH Prog (17 hydroxyprogestrone) gt 6 mmol/l
• Ovarian adrenal androgen secreting tumours
• Very high testosterone gt 6mmol/l

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• Cushings Syndrome
• - Dexamethsone suppression test
• - 24 hours urinary cortisol
• - DHEAS (Dehydroepiandrosterone) gt 13 mmol/l
• Iatrogenic and illegal androgen ingestion.
• Hypothyroidisms (Thyroid profile test).
• Hyperprolactinemia. (Serum Prolactine estimation)

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Homoeopathic approach
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• Miasmatic Analysis

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PCOD
psora
sycosis
tubercular
Psora initially brings about functional changes
in the form of neuro hormonal pathway leading to
hormonal changes.
syphilis
Sycotic miasm brings about pathological changes
in OVARIES leading to formation of CYSTS.
Tubercular miasm adds bleeding to the CYST.
Malignancy
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• Repertorial Analysis
• Different Rubric given in
• various Repertories

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• 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 Repertory
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• 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.

BBCR Repertory
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• GENITALIA - Female organs - swollen ovaries
  GRAPH. LACH.

• GENITALIA - Female organs - swollen - ovaries
  double Apis bufo nux-m.

BBCR Repertory
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• 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 Repertory
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• 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 Repertory
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• Pulse - FAST, pulse, elevated, exalted - ovarian
  cyst, in Iod.

• Pulse - IRRITABLE, pulse - ovarian cyst,
• in Iod.

Murphy Repertory
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• 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.

Synthesis Repertory
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Some Rare Remedies for PCOD Given in different
Materia Medicas
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• 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
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• Cobaltum nitricum (nitrate of cobalt)

• Female
• Lack of libido. Metrorrhagia. Secondary
  amenorrhea.

• Cystic inflammation of the ovary. Sterility

-MURPHY R., Homeopathic Remedy Guide
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• 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
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• 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.

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• 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.

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Ovininum Ovary gland (Oophorinum)

• Ovary has been suggested as a remedy in ovarian
  cysts.

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• 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
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• 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
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• Argentum metallicum
• Hard, indurated, cystic ovaries, especially the
  left.

FARRINGTON E. A., Comparative Materia Medica
(with therapeutic hints)
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• 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
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The Important Common Homoeopathic drugs indicated
for Ovarian cysts are

• Bovista
• Apis mellifica
• Platina
• Lycopodium
• Thuja
• Lachesis

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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.

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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.

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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

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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.

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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.

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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.

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Bufo

• Burning heat and pain in the ovaries which
  extends down the thigh.
• Dysmenorrhoea with cysts and hydatids about
  ovaries.

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Iodum

• Congestion and dropsy of right ovary with
  dwindling of the mammae.
• Dull pressing pain extending to the uterus.
• Wedge like pain in the right ovarian region.

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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.

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Conium Mac.

• Ovary enlarged, indurated, lancinating 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.

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Colocynthis

• Boring pain in ovary.
• Must draw up double, with great restlessness.
• Round, small, cystic tumous in ovaries or broad
  ligaments.
• Bearing-down cramps, causing her to bend double.

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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.

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Other Rare drugs indicated for Ovarian cyst

• Oophorinum
• Aur. Iod.
• Xantoxylum

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