Polycystic Ovary Syndrome (PCOS)

Polycystic ovary syndrome (PCOS) refers to a spectrum of clinical problems due to hormonal and metabolic imbalance, which can affect the reproductive and endocrine systems.

 

 

How Common?

PCOS affects 5-10% of all women of childbearing age regardless of race or nationality. It may begin during puberty and become more severe with time.

Causes

The cause of PCOS is unclear. Multiple mechanisms may be involved in causing the disruption of the relationship between the ovary, hypothalamus-pituitary, adrenal glands and the metabolic system (elevated insulin level and often refers to as hyper-insulinaemia). Between 25 and 75% of patients have some evidence of insulin resistance. Luteinizing hormone (LH) levels are typically elevated with PCOS and follicle-stimulating hormone (FSH) levels are normal or low, but this hormone pattern alone is not diagnostic of the disorder. The androgen (male hormones) level may be elevated in some women with PCOS.

Symptoms and Signs

  • Irregular menstrual bleeding resulting in periods of light flow along with heavy flow. There may be increased interval between periods, often up to several months. Some may not have periods for a prolonged period of time (such as only one or two menses in a year).
  • Overweight or obesity.
  • Infertility (difficulty in conceiving); miscarriages.
  • Effect of imbalance hormone (with predominant increase of male hormone effect) such as acne, oily skin, thinning of the scalp hair (alopecia), hirsutism (increased hair growth on the face, arms, legs and from pubic area to navel).

Diagnosis

Diagnosing PCOS can be difficult. Other similar disorders that can affect the endocrine and metabolic system should be excluded first before this diagnosis is made. The syndrome has a number of diagnostic symptoms with no single diagnostic test. Criteria for diagnosis will include the following features :

  • Polycystic ovaries as seen with the ultrasound scan of the pelvis – these are fairly common and involve ovary enlargement from many small cysts.
  • Clinical effects due to increased male hormone (hyperandrogenism), such as acne, oily skin, thinning of the scalp hair (alopecia), hirsutism (increased hair growth on the face, arms, legs and from pubic area to navel).
  • Absence of ovulation – the monthly release of the egg from the ovary fails to take place, resulting in irregular menstrual cycles and difficulty in conceiving.

Investigation

Ultrasound scan of the pelvic organs

Diagnostic tests may include:

  • Ultrasound scan of the pelvis to look for other causes of abnormal menstrual bleeding (if present) and the ovaries (look for the typical polycystic appearance).
  • Female hormonal evaluation, especially in those with very scanty or irregular menses.
  • Male hormone evaluation if there is an increased male hormone effect
  • Exclude diabetes via an oral glucose tolerance test
  • Blood lipids level
  • Endometrial Biopsy in those with prolonged and heavy menstrual bleeding.

Preventive measures

Cannot be prevented at present. Maintenance of ideal body weight will help to prevent many of the other metabolic and menstrual effects of the PCOS.

Possible Complications

  • Diabetes mellitus
  • High cholesterol and triglyceride levels.
  • Cardiovascular disease; high blood pressure.
  • Endometrial cancer (cancer of the uterine lining) in those with irregular and/or prolonged interval of menstrual cycles (eg only a few menses in a year)
  • Gestational diabetes or impaired glucose tolerance during pregnancy. Possible higher miscarriage rate

Treatment

Treatment for this disorder depends on the presenting problems, the severity and whether there is a need for pregnancy. The treatment chosen should also help to reduce the long-term metabolic and menstrual consequences.

  • Overweight or obese woman should aim to reduce their weight. This should incorporate a structured healthy diet and exercise program. Lifestyle adjustment is important, even for normal weight women.
  • Infertility is usually treated successfully by improving diet and exercise, weight reduction and drug therapy. If these measures are not successful, conception can be achieved by additional drug therapies, laparoscopic ovarian surgery and assisted reproductive techniques.
  • Cigarette smoking should be discontinued due to risk of cardiovascular problems and diabetes.
  • Options for removing excess hair from your face, arms and legs include medications, bleaching, electrolysis, laser therapy, plucking, waxing, and depilation.
  • Hormonal therapy such as progestogens or combined oral contraceptive pills is often used to treat abnormal menstrual bleeding.If pregnancy is not required, these pills can be continued to regulate menses. Progestogen pills is a better choice to regulate menses in those with no need for contraception (instead of birth control pills).
  • If pregnancy is desired, then ovulation induction medication (such as clomiphene) is given to improve fertility. This works by stimulation of ovulation and timed coitus to increase the chances of conception.
  • The modern combined oral contraceptive pills can also help to reduce the excessive male hormone effects. Women will see an improvement in severity of acne and hirsutism after 4 to 6 months of therapy.
  • Insulin-lowering medications such as metformin may be prescribed in certain clinical conditions to improve fertility and reverse the adverse metabolic changes associated with PCOS especially in overweight or obese women and the abnormal glucose tolerance test is abnormal.
  • Regular follow-up with the doctor is important for early detection and treatment of potential endocrine, gynaecological and metabolic complications such as diabetes, hyperlipidaemia, cardiovascular disease and womb (uterine) cancer.

 

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Hysteroscopy (diagnostic and operative)

The hysteroscope is a small lighted telescope used for visual examination of the cervix and the uterus to help diagnose and treat abnormalities in the cervical canal or the uterine cavity. If it is used to look for the cause of the presenting problem, it is term as diagnostic hysteroscopy. If it involves some form of surgical procedures such as removal of growths (endometrial polyps or fibroids), removal of the lining or separation of adhesions, then it is called operative hysteroscopy. In many cases, both procedures are done concurrently – the so-called “see and treat” approach.

Reasons for the procedure

  • Evaluation and treatment of abnormal uterine bleeding.
  • To look for the displaced and removal of the intrauterine device (IUD).
  • Evaluation for infertility (difficulty in conceiving) or recurrent miscarriage.
  • Uterine polyps, fibroids or adhesions (which is called Ashermann’s syndrome).
  • Obstructed fallopian tubes.
  • Congenital malformations of the uterus

Preparation for the procedure

Ideally, it is best to schedule the procedure following completion of menstrual flow when the lining is at its thinnest. However, this is sometimes not possible, especially when it is done for abnormal uterine bleeding. It can be done either as an

  1. Out-patient procedure, without any anaesthesia or analgesia – this is possible because of the small caliber of the hysteroscope and no cervical dilatation is required. Therefore, this will reduce discomfort significantly. Fasting is not required. However, it is not advisable to take a full meal just prior to the procedure.
  2. Day-case procedure, usually under a light general anaesthesia. You are required to fast for at least 6 hours before the procedure (no food or drinks at all for 6 hours). For example, if the procedure is in the morning, you should skip breakfast. If it is in the afternoon, you can have an early light breakfast (e.g. tea/coffee/milo and toast) but make sure that this is taken at least 6 hours before the procedure. Please reconfirm this with your doctor.

Description of procedure

  • It is sometimes performed in combination with a laparoscopy.
  • The hysteroscope is passed through the vagina and cervix into the uterine cavity for viewing. Saline fluid is used to distend (expand) the uterine cavity to improve visualization and allow any operative manipulations to be achieved. Video monitoring is often used at the same time.
  • For operative hysteroscopy, a variety of small surgical instruments are available for use in hysteroscopic procedures including scissors, special clamps, or wire with electro-cautery attachment for coagulation and cutting. One attachment is a “rollerball” or wire loop through which electrical heat travels to remove (resection) the fibroid or endometrial lining. After the uterus is filled with fluid to enlarge it for better viewing, the doctor moves the roller¬ball back and forth across the lining or uses the wire loop to shave off the tissue. This method is called endometrial ablation. The wire loop can be used to remove the submucous type of fibroids. This is called hysteroscopic resection of fibroid.
  • The hysteroscope is then withdrawn.

Complications

For diagnostic hysteroscopy, the risk of is very low. This includes  uterine perforation or excessive bleeding. For operative hysteroscopy, the complication rate is slightly higher and includes:

  • Pelvic infection.
  • Cervical trauma due to dilatation and manipulation during surgery
  • Excessive fluid absorption into the blood circulation.

Post-procedure care

If performed as an office procedure without any anaesthesia – the recovery is immediate. You will be allowed home as soon as you have finished the consultation with your doctor. It is best if you have someone to drive you home.

If performed as day-case under general anaesthesia:

  • Following the procedure, your vital signs will be monitored for a period of time.
  • Once the anaesthetic effect has wear off and you are fully awake, you will be allowed to go home. Please arrange for someone to drive you home.
  • There may be some slight bleeding and cramping. The fluid used during the hysteroscope will flow out for one to two days. Use sanitary napkins—not tampons—to absorb blood or drainage.
  • Antibiotics may be prescribed prior to and after the procedure to prevent infection. This is uncommon and usually not required.
  • Medicine for pain may be given during or after the procedure.
  • Rest at home during the remainder of the day. Additional restrictions may be required depending on the extent of the surgical procedure.
  • Avoid sexual intercourse for 2 weeks or as directed.
  • There is no special dietary restrictions.

See your doctor immediately if there is:

  • Excessive bleeding.
  • Abnormal vaginal discharge.
  • Increasing abdominal pain or abdominal distention
  • Signs of infection develop, such as headache, muscle aches, dizziness or a general ill feeling or fever.

 

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Anaesthesia and Analgesia in Obstetrics and Gynaecology

Dr. William Morton demonstrated the first public administration of ether anaesthesia in the operating theatre of the Massachusetts General Hospital on the 16th October 1846
That day is remembered as a milestone in anaesthesia and celebrated as World Anaesthesia Day.
From that date onward, many progresses have been made in the field of anaesthesia, and more so specifically for the practice of obstetrics and gynaecology.

On the 16th August 1897, a German surgeon by the name of Dr. August Bier administered the first spinal anaesthetic. Spinal anaesthesia becomes one of the most popular methods of administering a patient pain free from surgery of the lower limbs, lower abdomen and Caesarean sections and is still widely used.

Read moreAnaesthesia and Analgesia in Obstetrics and Gynaecology

Suction evacuation for miscarriage

Suction & evacuation is a technique of emptying the uterus of a pregnancy. It can be used to terminate a pregnancy or to remove a fetus that has died. It involves the removal of a fetus and accompanying tissue of the pregnancy from the uterus with instrumental evacuation through the vagina and is usually performed in the first trimester of pregnancy.

Reasons for procedure

Read moreSuction evacuation for miscarriage

Combined oral contraceptives (COC) pills

The reason for practicing contraception (or birth control) is to prevent an unplanned pregnancy. Most methods of contraception enable sexually active couples to temporarily avoid pregnancy. Permanent birth control is accomplished through sterilization. There are many types of birth control methods that are currently available. There is no perfect method at the moment. Each has its own advantages and disadvantages. Be sure you know and understand the different types of birth control available to you, the risks and benefits of each, and any side effects, so that you can make an informed choice.

Read moreCombined oral contraceptives (COC) pills

Cervical Intraepithelial Neoplasia (CIN)

Cervical intraepithelial neoplasia (or CIN) refers to the presence of abnormal cells seen on the cervical cytology smear. These abnormal cells are obtained from the lining of the outer cervix and can range from mild to severe changes. A diagnosis of CIN changes is not cancer. However, the severe form of dysplasia can be considered a precancerous condition and may eventually progress to cancer in several years if not treated.

The cervical cytology smear was previously referred to as Pap smear. Currently, the newer cervical cancer screening uses a liquid based cytology and the commonest one used are: Thin Prep or Sure-Path. These are better and more accurate compared to the conventional Pap smear test.

Classification of CIN 

Read moreCervical Intraepithelial Neoplasia (CIN)

Endometriosis

Endometriosis is a condition whereby tissues from the lining (endometrium) of the uterus becomes implanted in areas outside the uterus such as the outer surface of the uterus, the fallopian tubes or the ovaries. Rarely, the endometrial tissue may spread beyond the reproductive organs and pelvic region.

In a normal menstrual cycle, the endometrial tissues respond to cyclical female hormones and becomes progressively thicker and will eventually shed each month if the woman is not pregnant. It is discharged as menstrual flow at the end of each cycle. In endometriosis, this shedding and bleeding will occur outside the uterus as well, causing significant pain. Recurrent bleeding and healing cycle will eventually cause scar tissue formation and destruction of pelvic structures. The excessive blood will accumulate over a period of time and eventually forms a cyst in the ovary (called endometriotic cyst or endometrioma).  The 4 stages (classification) of endometriosis (minimal, mild, moderate or severe) are used to describe the location and the severity of the disorder.

Read moreEndometriosis