polycystic ovarian disease by dr.shuchita chattree
TRANSCRIPT
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.
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
•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
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.
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.
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
• Increase activity in chromosome CYP17 region leads to increased p450c17 enzyme and hence increased androgen synthesis.
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.
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
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]
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.
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.