PolyCystic Ovarian Syndrome and Fertility Series Part 3

PolyCystic Ovarian Syndrome and Fertility Series Part 3

In the last 2 parts of this series (Part 1 here and Part 2 here), you have come to know more about PCOS and what are the health consequences of PCOS. The last thing that is left is how to take your step to fight back. You must take the first step in this journey towards freedom from PCOS.

Lifestyle Changes

I’m sure most of the women with PCOS, who are overweight or obese, are familiar with a common advice given by their doctor: “ Please lose some weight”. Am I right?

The first and foremost action to take is to lose weight. Years of research has confirmed the advantage of weight loss in the treatment of PCOS. Studies has shown that even with a weight loss of 5-10%, it can regulate the women’s period cycle. The weight reduction can also improve the probability of ovulation in the women.

 

Image Source: Pexels

What’s the recommended way to lose weight ? There is no special regime for PCOS. You can follow any weight loss programme that you are comfortable with. The usual weight loss programmes consist of nutritional classes, dietary modifications and exercise. In very severe cases, bariatric surgery is recommended to lose weight.

As I have mentioned earlier, insulin level also plays an important role in obesity. Treatments to lower your insulin level can also help you to lose weight. Common medication used to lower body insulin is called ‘insulin sensitising agents’ such as Metformin.

If you are a smoker, it’s a good idea to try to cut down or completely stop smoking. This is because smoking has been shown to increase androgen (male hormone) level in the body.

Image Source: Dreamstime.com

Too much of facial hair can be treated with simple measures such as waxing and shaving. There are many commercially available products that can do this. Laser hair removal is also effective. There are oral tablet and creams which can reduce hair growth but you need to be cautious if you are planning for pregnancy.

Medical Management

Medical management in combination with lifestyle changes is a very effective arsenal in combating PCOS.

Types of medical management is tailored to the women depending on her fertility wishes.

Image Source: Very Well Family

Doctor, I want to get pregnant:

The major concern in PCOS is inability to ovulate.

1. Weight loss is an effective way to re-start the women’s ovulatory cycle. However, it does not help all women.

2. Some women need to take ovulation inducing medications to ‘kick start’ her egg development. Commonly used medications in this group are oral tablets such as clomifene citrate, tamoxifen and letrozole. Sometimes, the medications are given in an injectable form if the women do not respond to oral medications. The danger with injectable medication is over-stimulation of the eggs, since the injectable medication is generally more powerful in their action. Your doctor may even give you oral plus injectable medication to control egg development.

The oral medications are also given in combination with Metformin. There are many combinations but your doctor will be able to tailor-make a combination that suits you best.

Image Source:  Dr Seyed Mehdi Ahmadi

3. When a women with PCOS failed to respond to oral or even injectable medications, sometimes a keyhole (laparoscopic) surgery called ‘ovarian drilling’ is recommended. In this surgery, few tiny holes are made on each ovary. This surgery has been proven to help with ovulation. However, with the availability of IVF (in-vitro fertilization) treatment, this surgery is rarely done now.

Once a women establishes her ovulatory period cycle, she has a good chance of getting pregnant naturally. In the event this does not happen, simple treatments such as an IUI (Intra-Uterine Insemination) can be tried. In some cases, more advanced treatment in the form of an IVF will be needed.

Take home message is: If you are keen for a pregnancy, you need to ovulate first regularly!

No doc, I don’t intend to get pregnant yet:

Even if you don’t intend to conceive yet, lifestyle modification as mentioned above is very important. It improves PCOS symptoms and also your general health.

Image Source: Lloyds Pharmacy

The most common medication used in a women with PCOS who do not have regular periods is oral contraceptive pill or birth control pills (OCP). OCP can regulate a women’s period such that she will have a regular monthly bleeding. It also can reduce the amount of bleeding and this is useful for someone with heavy bleeding. Many women also complaint of painful periods and OCP is effective in treating this.

Certain OCP contain a hormone which can reduce a women’s male hormone level and this is particularly useful in PCOS. In certain circumstances, OCP is used together with androgen-lowering medication (to reduce level of male hormone).

In addition to this, yearly medical check-up for Diabetes and high blood pressure is recommended.

Take home message is: Even if pregnancy is not a concern for now, you still need to make sure that you have periods at least 3-4 monthly!

Image Source: iStock

Isn’t prevention better than cure? Why a woman needs to go through all this when she can prevent PCOS?

The straight forward answer to this is there is no preventive measures for PCOS. You can’t prevent PCOS but early diagnosis and treatment can prevent it’s complications such as metabolic syndrome, obesity, heart disease and infertility.

Finally, I hope with a better understanding of PCOS, every women who has been diagnosed with PCOS can stand up now and fight back. PCOS is not your fate but just a temporary road-block in achieving a well balanced healthy life style.

You don’t have to suffer in silence anymore!

Download Teleme’s mobile app and consult your nearest gynaecologist

Dr. Agilan Arjunan

Dr. Agilan Arjunan

Obstetrician & Gynaecologist (infertility)

 

PolyCystic Ovarian Syndrome and Fertility Series Part 2

PolyCystic Ovarian Syndrome and Fertility Series Part 2

In PCOS and Fertility Series Part 1, you have learned about what is PCOS and how you get to know if you have PCOS. In this part 2 series, we will continue with how PCOS can affect your health.

General Health Consequences 

PCOS can lead to general health condition known as metabolic syndrome. Metabolic syndrome consist of a cluster of problems, namely high blood pressure, high blood sugar level, increased fat around the waist and increased body cholesterol level. This occurs because PCOS leads to insulin resistance.

Insulin resistance is a condition where the body does not respond appropriately to a given level of body insulin. Insulin in a natural body hormone, produced by the pancreas,  that regulates metabolism in our body. Insulin regulates sugar level by controlling the intake of sugar into our muscle and fat cells and also production of sugar from the liver. Hence, in PCOS, the body cells does not respond to insulin as they should be. This leads to sugar not being utilised by muscle and fat cells properly and it also increases production of sugar by the liver. This leads to increased sugar level in our body.  Insulin resistance also leads to increased fat release into our circulation from fat cells.

This phenomenon of insulin resistance puts a woman at increased risk of developing Type 2 Diabetes Mellitus, increased blood pressure and high cholesterol. The combination of all this will finally increase the risk of heart disease.

Significant number of women with PCOS are overweight and obese. The usual complaint is they are putting on weight even with a careful and strict diet. This is related to insulin resistance and a high level of circulating insulin in the body. High insulin level is associated with weight gain in a woman with PCOS. So now you know that it’s not entirely your fault for not losing weight, its the insulin!

Image Source: Stockfresh

Fertility and Reproductive Health

In PCOS, the women often misses her periods. Do you know why ?

First of all , you need to understand the basic hormonal mechanism of your menses (period). In a typical 28-days period cycle, a woman’s egg (1 egg each period cycle) takes about 14 days to develop and released (ovulate) by Day 14 of the cycle (Day 1 is the first day of menstrual flow).  During egg development, the capsule of the egg releases hormones that starts to thicken the lining of the uterus. After ovulation, the left over capsule of an egg further produces hormones that thickness the lining of the uterus to its maximum. If there is no fertilisation of the egg ( that means the man’s sperm did not enter the egg), the woman typical sees her period 14 days from ovulation (ie Day 28 from her first day of menses). The duration of the second half of the period (ie after ovulation), is quite constant.

In PCOS, more often than not, the duration of egg development is quite long. It takes more than usual 14 days to develop. For example, if the egg takes 20 days to develop and ovulate, the woman will typically see her period on Day 34 of her cycle ( 20 days + 14 days= 34 days). A significant number of women do not ovulate at all for many months and they typically see only a few periods a year or not at all.

So, women with PCOS typically present with long period cycles or no period at all and their main complaint would be inability to get pregnant. This is due to lack of ovulation.

However, not all women with PCOS have problem conceiving. Some do get pregnant naturally with ease. So problem solved? Hold your horses, PCOS increases certain risk even in pregnancy.

The most important risk is Diabetes in pregnancy or known a Gestational Diabetes Mellitus (GDM). Remember about insulin resistance ? This phenomenon does not disappear once you get pregnant, in fact it continues. Insulin resistance can worsen and give rise to GDM.

GDM has a few unwanted adverse effects in pregnancy. It can lead to ‘big baby’ (macrosomia) with associated birth complications, preterm labour and intra-uterine fetal death.

The woman also faces increased risk of miscarriage in pregnancy. Research has shown that miscarriage rates in women with PCOS is about 2-fold higher. Some data also suggest miscarriage rate between 30-50% for women with PCOS undergoing fertility treatment.

The reason for increased risk of miscarriage could be a combination of insulin resistance, obesity and Diabetes in pregnancy.

Risk of Cancer

Image Source: Studio Radiologico Casalotti

Another important consequences of PCOS which is least spoken about is risk of developing womb cancer (endometrial cancer).

In a women with PCOS who sees very few periods in a year or in whom there is no periods, the lining of uterus (endometrium) is often very thick. This is due to a combination of prolonged development of egg which prolonged the hormonal exposure of the uterine lining and no periods (which means no shedding of the thickened uterine lining).

Generally, women are advised to have periods at least once in 3-4 months. A very thick uterine lining if left for a long time, can cause the cell in the uterine lining to change into what the doctor’s call ‘hyperplasia’. Hyperplasia means increased rate of reproduction of cells. This is can lead to development of cancer if left unchecked for too long.

Since you now know the consequences of PCOS, you may be wondering if there is any way you can cure PCOS. Unfortunately, there is no cure for PCOS. However, you can treat PCOS with lifestyle changes and medical management and that’s what you will learn in Part 3 Series: “What can I do to help myself?

Sources: NHS, MedicineNet, American Diabetes Association, American Cancer Society

Download Teleme’s mobile app and find your nearest gynaecologist here.

Dr. Agilan Arjunan

Dr. Agilan Arjunan

Obstetrician & Gynaecologist (infertility)

 
PolyCystic Ovarian Syndrome and Fertility Series Part 1

PolyCystic Ovarian Syndrome and Fertility Series Part 1

PolyCystic Ovarian Syndrome (PCOS) is a condition that has been diagnosed for over 75 years ago but yet many women still has little understanding of PCOS, let alone combat it.

“Just a few days ago I saw a couple who were married for 8 years and trying to conceive for nearly 6 years. She had seen a few general doctors over the years and was told that she has ‘imbalanced hormones’. She was given tablets to induce her periods and to make her ‘eggs’ to grow.”

This simple real life example illustrates how much PCOS can affect a women’s life on a long term basis. Appropriate diagnosis and treatment can save time, money and most importantly avoid unnecessary emotional trauma and guilt.

Many women have been diagnosed with ‘imbalanced hormones’ when they have irregular periods. Many of them probably have PCOS but undiagnosed. So what is PCOS ?

Image Source: Abounding Hope

PCOS is a condition in which female and male hormones are not in their usual balance. PCOS is one of the most common hormonal endocrine disorder in women. Let’s look at some facts:

1. It affects about 5-10% of women. However, less than 50% of this women were diagnosed correctly.

2. Studies has shown that nearly 70% of women suffering from infertility (due to difficulty ovulating) have PCOS.

3. In addition, nearly 40% of women who suffer from Diabetes / glucose intolerance have PCOS.

How do you know if you have PCOS ?

Image Source: iStock

The diagnostic criteria for PCOS has evolved over time as we gain more insight into this condition. Currently, PCOS is diagnosed based on your medical history, physical examination, ultrasound scan of your ovaries and with/without a blood test.

What are the common complaints a women with PCOS tells her doctor ?

  1. “Doc, I have very few periods in a year or a long interval between periods.”
  2. “I’ve been putting on weight even with careful diet and exercise! It’s like my body is resistance to exercise.”
  3. “I have put on weight since marriage. I used to weigh 55kgs and nows I’m 70kgs!”
  4. “I’m getting bit worried doc. My friends said that I have more facial hairs now than before. I realised that too cause even my regular hairdresser had pointed it out!”
  5. “We are married for 3 years now and no luck with pregnancy.”
  6. “The other doctor told me that I have many cysts in my ovary. Do I need a surgery?

These are some of the common worries that a woman with PCOS has.
The doctor would then proceed to examine the women. What are we expecting to see?

Image Source: Tribun News

An ultrasound scan of the ovaries may show ‘high number of  resting eggs’, usually more than 10-12 on each ovary. The resting eggs are arranged in a particular fashion known as ‘Ring of Pearls’.

Sometimes your doctor will arrange a blood test to look at female hormone imbalance and also at the level of male hormone (Yes, you read it correctly. Women have male hormone in them but in a low level). In PCOS, the male hormone level can be higher than usual.

“Mrs JC visited me for inability to get pregnant for 4 years. She has been putting on weight for the last 2 years despite on diet control. She has been noticing that she needs to shave and thread her facial hair more frequently now than before. She has sometimes missed her periods and her average period cycle length (from Day 1 to Day 1 of next period) is about 30-40 days. She used to have regular monthly periods at her teenage years. Her ultrasound scan of her ovaries showed a typical ‘Ring Of Pearls’ ”.

Image Source: News Karnataka

The problems of PCOS may not necessarily manifest itself early in life.  Sometimes the symptoms begin in late teenage years or more often in their 20s-30s. Many only knew they are suffering from PCOS once they have visited their fertility doctor.

It’s scary isn’t it? To live with a condition and never knew you ever had it. However, you won’t be terrified once you know what is PCOS, what are the health consequences and how to minimise or overcome the consequences.

Read about PCOS and Fertility Part 2 here.

Download Teleme’s mobile app and find your nearest gynaecologist here.

Dr. Agilan Arjunan

Dr. Agilan Arjunan

Obstetrician & Gynaecologist (infertility)

 

How to Improve My Chances of Getting Pregnant

How to Improve My Chances of Getting Pregnant

Treatment options for infertility can not guarantee a 100% success. However, YOU and your partner can help to improve the success rate. Every effort and step to achieving your goal of holding your little sunshine is worth trying. There are some aspects where the male and female partners can play a role.

1. Knowing your most fertile period ( fertile window)

Image Source: icanhelp.in

Fertile window is the time in the month when the women is most likely to become pregnant. This window is usually the 6 days interval ending on the day of ovulation. Ovulation occurs about 14-days prior to next period , so in a woman with 28-days period cycle, ovulation occurs on day 14 of her menses (Day-1 is when the woman starts to bleed).

2. Knowing when you will ovulate (releasing the egg into the Fallopian tube)

The knowledge of when you might ovulate will help you increase your chances of getting pregnant naturally. Methods you can use are:

Image Source: Very Well Family

a) Cervical mucous changes: Cervical mucous and vaginal discharge will increase 5-6 days prior to ovulation and peaks 2-3 days before ovulation. When you are nearing ovulation, cervical mucous will be more abundant, takes on a more raw-egg-white-like consistency. It will also be more stretchy in between your fingers.  This method is easy to do and also helps you know your body better.

b) Basal body temperature: Your body temperature will increase by 0.1 – 0.2 degree celcius once you have ovulated. You need to measure your body temperature everyday at the same time before your are up from your bed and chart it. If your body temperature rises, it indicates that you HAVE OVULATED. It means that this method tell you that ovulation had happened, it does not predict ovulation.

Image Source: Shutterstock

c) Urine Test for ovulation: There are commercial test kits available to test your urine for ovulation.  It measures a hormone called Lutenizing Hormone (LH), a hormone that helps ovulation. The LH hormone peaks in the body about 2 days prior to ovulation. When the LH hormone level is peaks in the body, it is measured in the urine. A positive test indicates that ovulation may occur in 24-48 hours.

d) Other general signs:

i) Increased sexual drive: This is nature’s way of telling you when you are fertile. However, sexual drive can also be provoked by many other factors.

ii) Breast tenderness: It can occur just before or after ovulation. Just like increased sexual drive, breast tenderness can be due to other reasons such as it can occur just before menstruation.

iii) Position of your cervix: Cervix is also known as neck of womb. Cervix, at the time you are not fertile, is easily felt vaginally, firm and closed. During fertile period, cervix will move higher, soft and open. Some says it feels firm like tip of your nose when you are not fertile and soft like your lips when fertile. Cervix is felt by inserting your clean middle or index finger gently into vagina. Find a comfortable position to do this such as sitting on a toilet bowl, equating or placing one leg up on the edge of a toilet seat.

3. General health

Image Source: iStock

You must make sure that you are healthy enough before a pregnancy. If you have any underlying illnesses such as Diabetes Mellitus or high blood pressure, make sure it is well controlled. Uncontrolled illnesses not only makes it difficult to get pregnant, but you run a higher risk of complication during pregnancy. You should also take pre-conception vitamins such as folic acid. You should stop smoking and stop consumption of any recreational drugs (ie marijuana, cocaine).

4. Give more time

Sometime, just giving a little more time is all what you may need. Generally, after 1 year of trying to conceive, 80% of couple will succeed. If given another year , 90% of couples will succeed. However, pregnancy rate reduces in older women and men.

5. Timed sexual intercourse

Research has shown that increasing the frequency of sexual intercourse may improve your chances. You should have sex every 1-2 days during your fertile period.

6. Watch your diet

Image Source: Fit Way

You should aim to maintain an ideal Body Mass Index (BMI) of 24kg/m2 or less, if possible. Obesity and being underweight has been shown to have adverse effect on fertility. Foods high in Mercury (seafood such as shark, swordfish and king mackerel) can reduce fertility. Heavy alcohol and caffeine intake are also shown to affect fertility.

7. Does sex position matters?

Well, this a question that has been asked time and again. Research did not find any relation between sex position and fertility. Resting on bed after sex are also not shown to affect fertility. However, usage of certain lubricants can reduce your fertility due to their chemical contents.

Download Teleme’s mobile app and consult Dr Agilan, Obstetrician & Gynaecologist (infertility)

Dr. Agilan Arjunan

Dr. Agilan Arjunan

Obstetrician & Gynaecologist (infertility)

Normal Fertility

Normal Fertility

1.Normal Pelvic Anatomy

Female reproductive organs consist of uterus (womb), Fallopian tubes and ovary. The uterus / womb is a hollow, peared-shaped organ with thick muscular wall. It is subdivided into corpus (body) and cervix (neck). The top portion of corpus is called fundus. The inner part of corpus is the cavity, where the embryo/foetus develops during pregnancy. The inner lining of the cavity is called the endometrium.

Every month, endometrium thickened in preparation for potential pregnancy and sheds during menstruation if pregnancy does not occur. The cervix (neck) allows sperm to enter the corpus during fertile period of a woman. The Fallopian tubes are the channel that connects the ovaries to the uterus.

The inner lining of the fallopian tubes is made up of finger like projections called the cilia. These cilia are important in assisting the movement of the female eggs (oocyte) towards the uterine cavity and the sperms towards the oocytes. The ovary are oval-shaped paired glands that are attached to each sides of the uterus. Every month, one of the ovaries releases an oocyte/female egg. The ovary also produces female hormones oestrogen and progesterone.

2. Normal menstrual cycle

Normal menstrual cycle length (from beginning of one period till the beginning of next period) average between 21-35 days. If you are menstruating regularly, most probably you are ovulating.

The first day of your bleed is considered Day 1 of your menses. A woman may bleed for 4-7 days, but it varies for every woman. During the bleeding phase of your menses, the endometrial lining is shed and becomes thin. The ovary now produces female hormone called Oestrogen, which slowly thickens the endometrial lining. At the same time, the ovary also produces and develops few early stage eggs or oocytes.

Subsequently, only 1 egg or oocyte will mature every month. By mid-cycle (approximately day 14 in a woman with 28 days menstrual cycle), the matured egg or oocyte will be released into the Fallopian tube. This is also called ovulation. The ovary now will secrete female hormone called Progesterone, which will support the pregnancy if it happens. If there is no pregnancy, the endometrial lining will began to shed and menstrual bleeding will start and the woman will be in her Day 1 menses again.

 3. How Do I Get Pregnant?

Pregnancy occurs when the sperm meets the egg or oocyte in the fallopian tube. Out of millions of sperms that reaches the oocyte, only 1 sperm gain entry into the oocyte. Once inside, the genetic materials (building blocks for human beings) of the sperm and the oocyte will merge to form the embryo (early stage baby). The embryo will then move through the fallopian tube to get implanted in the endometrial cavity.

4. What is my chances of getting pregnant?

Generally, the chances of getting pregnant decline with age. The older the women gets, the lesser her chances of getting pregnant, even with advanced techniques like IVF (test tube).

5.If I don’t get pregnant, is there a problem with me?

Not necessarily. Nearly half of infertility are caused by male/husband’s problem(male infertility). Thus, it is important that both partners undergo evaluation for infertility.

6.How long should I be trying before getting help to get pregnant?

If you do not have any known factors that can lead to difficulty in getting pregnant, you and your partner can try up to 1 year before getting some help. You should try to have regular unprotected sexual intercourse around the time of ovulation.

7.Where can i get help?

You could see your own family doctor to get initial advise. You could also get an appointment to see a fertility specialist. There are abundance of information available in the internet about infertility.

Download Teleme’s mobile app and consult Dr Agilan, Obstetrician & Gynaecologist (infertility)

Dr. Agilan Arjunan

Dr. Agilan Arjunan

Obstetrician & Gynaecologist (infertility)

Silent Pain: Endometriosis Treatment (Part 2)

Silent Pain: Endometriosis Treatment (Part 2)

What are the treatment options

Medical ( non-surgical) Management

The type of medical management depends on the severity of her pain symptom and whether she is trying to conceive.

If she is not planning for a pregnancy, pain killer medication from the group known as non-steroidal anti-inflammatory (NSAIDs) can control her pain symptom.

Usually the pain killers are given in combination with hormonal treatment such as a combined contraceptive pill (birth control pill which has both the oestrogen and progesterone components).

Image Source: Reader’s Digest

If the woman can not tolerate side effects of oestrogen , progesterone -only hormonal medications can also be used. These form of medications can be administered orally, in the form of 3-monthly injections, progesterone implant or as a intrauterine device.

In women who has severe symptoms and who are not concern with infertility , monthly or 3-monthly injection to temporarily “stop” her ovarian activity can be given. These injections are known as gonadotrophin releasing hormone analogue (GnRh analogue). These injections are commonly used with oral hormonal supplements to prevent bone loss. It is effective to alleviate pain symptom but the symptoms tend to recur once treatment is stopped.   

The other type of “ovarian blocker” is known as GnRh antagonist. It can be given  orally or as an injectable.

Image Source: Live Strong

For women who desire a pregnancy, unfortunately many of the hormonal or ‘ovarian blockers’ are not appropriate as they will prevent ovulation. Oral NSAIDs can be given for pain symptoms.

These woman should seek early advise from a fertility specialist. Many of them may need some form of assisted reproductive treatments to get them pregnant.

Surgical Management

Laparoscopy (keyhole surgery) is needed in most cases of endometriosis either as a diagnostic or a therapeutic tool.

For women with ovarian endometrioma (ovarian cyst resulting form endometriosis) or with deposits of endometriosis outside the uterus, laparascopy can be used to remove the cyst and destroy the endometriotic spots. These intervention may help to reduce pain symptom and is suitable for women who desire a pregnancy.

Image Source: IVF Surrogacy 

A more definitive surgical procedure is to remove a woman’s womb (uterus) with or without removal of her ovaries. This can be done via a laparoscopy or a conventional open surgery.

This is usually offered for a more severe pain symptom and for a woman who has completed her family.

Laparoscopic nerve ablation (destroying the nerve ends) has also been offered to reduce pelvic pain. However, their efficacy has not been established. 

Complementary Therapy

Acupuncture and diet modifications has been advocated as a possible therapy for endometriosis. Research has suggested possible therapeutic effect of acupuncture for period pain.

Image Source: Politeka

Research also suggest some correlation between diet and period pain but so far there is no effective dietary recommendation for prevention or treatment of endometriosis.

Conclusion 

Many women may suffer from a ‘silent pain’ due to undiagnosed endometriosis. Women who suffers from period pain or have difficulty getting pregnant should consult a specialist doctor and seek appropriate advise early, especially if they have endometriosis as no women should suffer in silence. 

Download Teleme’s mobile app and consult Dr Agilan, Obstetrician & Gynaecologist (infertility)

Dr. Agilan Arjunan

Dr. Agilan Arjunan

Obstetrician & Gynaecologist (infertility)

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