Polycystic ovarian syndrome: Enigma and ignorance

Summary

In polycystic ovary syndrome or PCOS, the name associated with the presence of multiple small cysts in the ovary, is related to anovulation, infertility and features due to higher than usual levels of male hormones. Alternative names used for this condition also include polycystic ovaries, polycystic ovary disease, Stein-Leventhal syndrome and polyfollicular ovarian disease. The signs and symptoms of PCOS manifest early after the first menstrual period during puberty. Excess androgen. Elevated levels of the male hormone can cause physical signs, such as excess facial and body hair (hirsutism), and sometimes severe acne and male pattern baldness. Unfortunately, frequently due to medical incompetence, the diagnosis is delayed till later life, compromising women's life quality. 

Polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a disease in which women has high levels of androgens (male) hormones. Many problems can occur as a result of this increase in hormones, including menstrual irregularities, infertility, skin problems such as acne and hair growth, and resulting psychological effects on sufferers. 

PCOS is linked to changes in hormone levels that make it difficult for the ovaries to release mature eggs. This also leads to the observation of ovarian follicles when an ultrasound scan is carried out. The reasons for the changes are not clear, as is the case with most disorders in medicine. The hormones affected in PCOS are estrogen and progesterone, the female hormones that help a woman's ovaries release eggs, and androgens, a male hormone found in small amounts in normal women. Normally, one or more eggs are released during a woman's menstrual cycle, a process that is known as ovulation. In most cases, the release of the eggs occurs approximately two weeks before the start of menstruation.

Most of the time, PCOS is diagnosed late in young women. Diagnosis is often not entertained in affected adolescent girls. Originally symptoms often begin when a girl's periods start. Affected girls often have a mother or sister with similar symptoms. Sadly, medics are not trained to consider the initial symptoms seriously, which include changes in the menstrual cycle, such as a missed menstrual period after having one or more normal menstrual periods during puberty (secondary amenorrhea ), irregular menstrual periods, range of period heaviness from very light to very heavy, extra body hair that grows on the chest and abdomen and around nipples and face, acne on the face, chest or back, skin changes such as thick or dark marks and skin folds around the armpits, groin, neck, and breasts. Gynaecologists and general practitioners are too arrogant to consider skin and hair changes to be a part of their consideration. This causes a diagnostic delay.

The consequence of a diagnostic delay

The textbooks written on PCOS describe as typical cases that are entirely a result of the professional incompetence of gynaecologists in making the diagnosis early. Development of male characteristics is not typical and not necessarily an outcome in PCOS, unless someone missed the diagnosis earlier on. When their own diagnostic incompetence afflicts sufferers, the 'experts' end up describing the following changes as typical sequelae: thinning of head hair in the temple area called male pattern baldness, clitoral enlargement, deepening of the voice, and decreased breast size. This should never happen in a health system that works well and pays attention to detail. Serious conditions associated with diagnostic delay lead to chronic conditions like insulin resistance and diabetes, arterial hypertension, high cholesterol, weight gain and obesity, and metabolic syndrome.

The healthcare provider, on suspicion of the diagnosis, may check weight, body mass index (BMI) and other bodily measurements. Blood tests may be done to check hormone levels, including estrogen, follicle-stimulating hormone, luteinizing hormone, male hormones (testosterone, DHEA), prolactin and thyroid functions. Other blood tests may include fasting glucose (blood sugar), tests for impaired glucose tolerance and insulin resistance, lipid levels amongst others. A pelvic ultrasound of the pelvis would need to look at the ovaries. If there is any doubt that a period delay may be due to pregnancy, a urine HCG test may be undertaken.

Treatment and prognosis

Weight gain and obesity is common in people with polycystic ovary syndrome. Losing weight, even in small amounts, can help treat hormonal changes, diabetes, high blood pressure, high cholesterol, etc. Birth control pills can make menstrual periods regular and, depending on the hormones in the pills, can also help reduce abnormal hair growth and acne. A diabetes medicine called Glucophage (metformin) may also be prescribed to make periods regular, prevent diabetes, and help lose weight. Effective hair removal methods include electrolysis and laser hair removal, and often these are repeatedly needed.

Other hormonal medications that may be prescribed include luteinizing hormone-releasing hormone analogs, clomiphene citrate and other medication that can cause ovaries to release eggs. Treatment to improve your chance of becoming pregnant should be given under supervision to detect multiple pregnancies early. With treatment, women with PCOS become pregnant close monitoring is needed as there is higher risk of spontaneous pregnancy loss, gestational diabetes and other complications.

Women with PCOS are more likely to develop endometrial cancer, diabetes, and obesity-related to complications

Conclusion

The wide variability of symptoms and signs associated with a universal disregard for concerns when they are first raised makes PCOS in women an enigmatic condition that exposes medical ignorance about its early diagnosis. The exact cause of PCOS is unknown. Early diagnosis and treatment along with weight loss can reduce the risk of long-term complications, such as diabetes and heart disease.

Author: Professor Khalid Khan

Epilepsy in women: Research into cessation of seizures

Summary

Epilepsy, a chronic condition with a continuous predisposition to experiencing epileptic seizures, has consequences for the sufferer. These include a negative impact on the neurobiological, cognitive, psychological and social function of the affected individuals and their families. Pregnancy affects epilepsy control and predisposes the offspring to a range of risks. 

Epilepsy

One per cent of the world population suffers from Epilepsy, a chronic condition with a continuous predisposition to experiencing epileptic seizures. It has consequences serious for the sufferer. There are over 50 million people affected, with a higher incidence in developing countries. Women and their pregnancies are particularly at risk. 

Epilepsy can cause disability through memory alteration and language, mental retardation, defects in reasoning, attention and concentration deficit, motor and learning difficulties, drowsiness and behaviour problems. These disorders influence the quality of life of the person suffering from epilepsy and trigger low self-esteem, loss of independence, restrictions on activities of daily living and social interaction deficit. Epilepsy is associated with psychiatric comorbidities and behaviour such as depression, anxiety, aggressiveness, fear of not being accepted and ideation suicide. 

Epilepsy in women

An epileptic woman, throughout her life, experiences various hormonal changes that influences the course of the disease. The hormones sex steroids, including estrogens and progesterone, have an influence on neuronal activity recurrently in each menstrual cycle. Up to a third of women can suffer hormone-dependent crises related to the menstrual cycle. Epilepsy affects all areas of the life of the sufferer including employment, marriage and parenthood.

Epilepsy and pregnancy

Pregnancy and epilepsy combined deserve special consideration because when they come together, they affect both the mother and the offspring. Antiepileptics drugs (AEDs) can have cause malformations in the fetus. During pregnancy, plasma concentration changes can alter the level of AEDs possibly triggering new seizures. Pregnant women with epilepsy also have a higher risk of neurological comorbidity with psychiatric illness, high economic cost, premature death, psychosocial dysfunction and reduction in quality of life.

There are more than a million women of fertile age with epilepsy in the world. In 1 out of 200 pregnancies, the mother can be epileptic. In Spain, it is estimated that among 400,000 epileptics, 62,800 are women of childbearing age (between 15 and 45 years old) who are likely to become pregnant. There is much disinformation in pregnant epileptics. There is a need to give the best advice possible without forgetting the psychosocial and economic aspects. Pre-conceptual counselling, antenatal care, administration of vitamin K and breastfeeding are all important areas to cover. 

Conclusion

Women with epilepsy during reproductive age need pre-conceptual counselling. Effect of sex hormones, endocrine changes and reproductive function impacts treatment and prevention of seizures, fertility and quality of life. During pregnancy control seizures is achieved through careful monitoring of AEDs while keeping in mind the effects on offspring. These special considerations make epilepsy in women a unique condition.

Author: Professor Khalid Khan

Nutrition in pregnancy: Mediterranian diet is advisable

Summary

A dietary pattern rich in health-promoting foods, including plant-based foods - fresh fruits and vegetables, whole grains, soya, nuts - with low levels of animal proteins and sugars, need to remain our priority. The most common causes of mortality like diabetes, obesity and cardiovascular problems respond to these simple nutritional interventions. New evidence shows that the Mediterranean diet during pregnancy has benefits both in maternal weight gain and prevention of gestational diabetes. These advantages can also help reduce the overall risk of complications for the offspring at the beginning of life. Effects of the Mediterranean diet during pregnancy will likely produce lifelong health benefits both for both mother and baby. 

Nutrition in pregnancy

Mediterranean diet is the Cultural Heritage of Humanity according to Unesco. It has been purported to be the best option whenever we seek to eat well. This is part of the reason why I moved to Granada, Spain. As a gynaecologist, I have also researched weight management and lifestyle in pregnancy. It goes without saying that healthy eating is essential during pregnancy, to protect the mother and the baby.

At a time when Coronavirus pandemic engulfed the Earth, does it surprise you to know that Diabetes remained at the top of the ranking of causes of mortality? Well, it just goes to show that our priority need not divert away from nutrition. A dietary pattern rich in health-promoting foods, including plant-based foods - fresh fruits and vegetables, whole grains, soya, nuts - with low levels of animal proteins and sugars, need to remain our priority. The quantity matters too. Key components of the Mediterranean diet are 30 grams of mixed nuts per day for an individual and half a litre of extra-virgin olive oil for cooking for an average family.

An update

New research into the Mediterranean diet during pregnancy has shown benefits both in maternal weight gain and prevention of gestational diabetes. These advantages can help reduce the overall risk of complications for the mother and the offspring. The benefits seen are observed in high-risk women who start pregnancy obese, with high blood pressure or raised lipid levels in the blood.

The implementation of the Mediterranean diet also appeared to be acceptable to women who previously had not been used to cooking and consuming almonds, hazelnuts, walnuts, olive oil, fruits and whole grains. This means that the Mediterranean diet can also be adopted by an ethnically and culturally diverse population.

A window of opportunity

Pregnancy offers a window of opportunity to address the issues concerning nutrition. Women tend to adopt a more healthy lifestyle in pregnancy. The medical profession should take advantage of this positive tendency to offer better nutritional advice. Improvements in this area will benefit not just the pregnancy but the whole family as the changes in the kitchen serve as an intervention for all at home. Avoidance of risk through healthy eating in pregnancy can become a lifelong habit.

Balanced diet taken the Mediterranian way will reduce later development of diabetes and cardiovascular problems. Cutting down on processed foods should become a lasting habit. Continued after pregnancy, the Mediterranean diet, rich in monounsaturated fatty acids and low in refined sugars, will improve health outcomes in the long run.

Conclusion

Pregnancy is a window into a better health future for the mother and the baby. A Mediterranean diet composed of at least 30 grams of nuts and extra-virgin olive oil reduces pregnancy complications and offers lifelong advantages to the newborn. What people know in Spain about how to cook and eat well can be learnt. It can be applied daily by incorporated elements of the Mediterranean diet into local cuisine. We can carry forward the enjoyment of garden salads, seasonal fruit, gazpacho, etc into life after pregnancy and forget about fast, pre-cooked food forever.

Author: Professor Khalid Khan

Chronic gynaecological pain: Insights into how to tackle long-term despair

Summary

It is important to make a profound change in the way we think about chronic pelvic pain. The notion that endometriosis is the sole cause of chronic pelvic pain is wrong; it delays correct diagnosis and leads to unrealistic expectations about treatment success. It is an outdated view perpetuated by many gynaecologists who are selective in their focus. Negative laparoscopy with persistent symptoms deserves as much, if not more attention and care. The key to managing a complex disease like chronic pelvic pain is to see it as a condition that cannot be cured but can be managed successfully. This idea is like the successful treatment of diabetes and hypertension, other chronic conditions which can be controlled. From the outset, a multimodal and a multidisciplinary approach is required.

Chronic pelvic pain

Lets first define what we are talking about. Chronic pelvic pain is non-cyclic or cyclical pain lasting more than 3 months located in the anatomical area of the pelvis, the anterior abdominal wall below the navel, the perineum, the genital area, the lumbosacral region, or the hip. It has a severity that causes functional disability or leads women to seek medical attention. The patients cannot exercise, have sleep disorders, experience difficulty enjoying free time, suffer poor socialization, have to put up with difficulties in mobility, find it hard to concentrate mentally, are negatively impacted on their quality of life, and their sexual enjoyment is enormously reduced. 

Acute pain is undeniably different from chronic pain. Acute pain is a symptom of tissue damage often associated with underlying disease. Chronic pain is by itself a diagnosis that needs recognition as a disease in its own right, with or without any additional pathology observed. At least 116 million adults in the United States suffer from chronic pain. This number is higher than the number of patients who have high blood pressure, diabetes mellitus, and cancer combined. Therefore, chronic pain has immense effects not only on the quality of life of sufferers but also on the health system and care delivery,

Focussing on diagnosing a single component of this condition, such as endometriosis or pelvic adhesions, for targeting treatment is unlikely to be successful in chronic cases. Given an understanding of chronic pelvic pain neuropathology, it is obvious that the above traditional approach is bound to fail; the condition needs to be addressed comprehensively with a multidisciplinary and multimodal approach from the outset. The key is to recognise the complex nature of the disease from the outset. The absence of positive clinical findings does not mean that one should minimize the meaning of the pain suffered by the patients. In these cases, a normal physical examination does not rule out the possibility of pelvic pathology.

Why does it matter?

Many ask the question: Why worry about a condition that does not kill? This silly viewpoint undermines the sufferer. Let's look at what is the actual dimension of the problem: The impact that chronic pelvic pain has is prominent. Approximately a third of all gynaecological outpatient visits, a quarter of all gynaecological emergency visits, and almost half of all gynaecological laparoscopies are performed for diagnoses related to chronic pelvic pain. Furthermore, nearly two-thirds of patients live without an accurate diagnosis or adequate treatment. No wonder it contributes to three-quarters of gynaecological disability and incapacity in the United States. It is estimated to generate in the United States a medical cost of approximately $1.2 billion a year and labour productivity losses of more than $15 billion a year with an inability to work fully for a majority of the sufferers

Endometriosis

Let's put endometriosis in perspective. It is clear that endometriosis is an important and frequent diagnosis. But, it is also known that pain can persist even after medical and surgical treatment. Not all chronic pelvic pain sufferers have endometriosis and not all endometriosis patients have pain. The severity of pain and the stage of endometriosis are not correlated. Minimal and mild endometriosis tends to be more painful than severe or deep infiltrative endometriosis. As many as a third of asymptomatic tubal ligation patients may incidentally be found to have endometriosis. 

Failure to cure the pain associated with endometriosis is linked to having intervened after making a wrong diagnosis, incomplete or insufficient treatments, or overlooking treatment of other contributing diagnoses. The diagnosis of endometriosis overlaps with several other painful pathologies. Endometriosis and painful bladder, the evil twin's syndrome, is one of many such combinations. Irritable bowel and myalgia due to pelvic floor tension also frequently co-exist with endometriosis. When endometriosis is suspected, diagnostic work should be comprehensive, including a systematic search for all other visceral or somatic causes of pain. Visual diagnosis of endometriosis should always be backed by tissue diagnosis confirmation at laparoscopy.

Beyond endometriosis

There is more than endometriosis that is worthy of attention. Women should be managed on the basis that there are multiple pain generators. The modern theories of chronic pain should be understood. When a primary pain generator persists and produces a prolonged painful stimuli, a neurological phenomenon is triggered that causes abnormal pain processing and inadequate central and peripheral responses. Secondary pain is then generated. Endometriosis, but also myofascial syndrome, fibromyalgia, irritable bowel syndrome, musculoskeletal causes, pelvic floor dysfunction, painful bladder syndrome, and peripheral neuropathies all are linked up in this way.

The exact mechanisms involved in the pathophysiology of chronic pain remain under investigation. However, it is believed that acute and long-term changes occur in both the central and peripheral nervous systems. Women who suffer chronic pain are victims of the vicious circle of pain-disability-pain. Among the various pain mechanisms involved are neuronal hyperexcitability, allodynia (pain with stimuli that are not painful in normal people) and hyperalgesia (pain more severe than that actually generated by a painful stimulus). There is the development of cross-talk in the pain pathways of the pelvic organs. Painful signals from the main organs of the pelvis, such as bladder, colon, rectum, and uterus overlap in way that focus on a single organ for directing therapy makes no sense. Given the implications of central and peripheral nerve sensitization in chronic pain, control of symptoms requires a broad, not narrow focus.

Conclusion

Given the current understanding of the neuropathy of pain, and the failure of single organ focussed traditional therapy, an integrated approach to treatment has the best chance of a successful outcome in chronic pelvic pain. The goal should be to educate the sufferer, to comprehensively diagnose her condition, to engage her in shared decision-making, to treat each of the multiple pain generators, and to target improving her life quality.

Author: Professor Khalid Khan