Polycystic Ovarian Disease And Its Homoeopathic Approach

By: Dr. Shuchita Chattree

M.D. (PGR)

Department of Materia Medica

Homoeopathy University, Jaipur

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Normal OvariesNormal OvariesNormal 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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Ovarian AttachmentsOvarian Attachments

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• 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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HistologyHistology• Ovary has 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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Stages of DevelopmentStages of Development•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.

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Menstrual CycleMenstrual Cycle•Normal Female Reproductive cycle is divided into two phases:

•Ovarian phase

• Uterine phase (Menstural cycle)

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Ovarian CycleOvarian CycleFollicular Phase•Menstural phase (1st-5th day)•Pre-ovulatory phase. (5th-13th days)

Ovulation Phase•Ovulatory phase. (13th-18th day)

Luteal Phase•Post-ovulatory phase. (18th – 28th days)

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Histological appearance during Reproductive Histological appearance during Reproductive CycleCycle

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Magnified ViewMagnified View

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Graffian Follicle

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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.

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Corpus AlbecansCorpus AlbecansIn 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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Formation Of CYSTFormation Of CYSTIn female reproductive cycle during follicular phase water starts accumulating around the egg cell, size increases as more water accumulate.

Because of accumulation of water Follicle comes to the periphery and Release of ovum ovulation occurs. 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.

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OocyteOocyte

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CYSTIC OOCYTECYSTIC OOCYTE

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Non Neoplastic Ovarian EnlargementNon Neoplastic Ovarian Enlargement

Follicular Cyst

Corpus Luteum Cyst

Theca Lutein And Granulosa Lutien Cyst

Polycystic Ovarian Syndrome

Endometrial Cyst

Except the last all are functional cysts of the Ovary and are loosely called CYSTIC OVARY

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Polycystic OvariesPolycystic 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 >10 mL in at least one ovary.

Epidemiology

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EpidemiologyEpidemiologyVery prevalent disease affecting between 6.5 and 8% of women overall

It is prevalent in Young Reproductive Age group (20-30%)

Prevalence much higher in obese women (28% versus 5.5%).

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HistoryHistory

Originally described by Stein and Leventhal in 1935, first known as the “Stein-Leventhal syndrome”.

They saw in 7 women with amenorrhoea, hirsutism, and obesity found to have a polycystic appearance to the ovaries.

Insulin resistance described later by Burghen (1980) 11/09/1430

ETIOLOGIESETIOLOGIES

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

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. 11/09/1432

PATHOGENESISPATHOGENESISThe 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(.

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(SHBG) can result in increased free androgens. 11/09/1433

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ABNORMALITIES OF PCOS OVARY

• 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.

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Clinical FeaturesClinical Features

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Diagnostic Criteria

ASRM/ESHRE, 2003 Criteria

2 out of 3 required

•1. Menstrual Irregularity

•2. Hyperandrogenism (Clinical or Biochemical)

•3. 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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Investigations:Investigations:• History-taking, specifically for menstrual pattern, obesity, hirsutism,

and the absence of breast development.

• BBT (basal body temperature)

• 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

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USG of Normal Ovary

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USG of Polycystic Ovary

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LAPROSCOPIC VIEWLAPROSCOPIC VIEW B/L Polycystic ovaries are characteristic of PCOS.

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DIFFERENTIAL DIAGNOSIS

• Late onset congenital adrenal hyperplasia

• DHEAS (Dehydroepiandrosterone) >18mmol/l

• 17 OH Prog (17 hydroxyprogestrone) > 6 mmol/l

• Ovarian + adrenal androgen secreting tumours

• Very high testosterone > 6mmol/l

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• 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)

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Miasmatic SymptomsMiasmatic Symptoms

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RubricsRubricsKENT’S REPERTORYKENT’S REPERTORY

FEMALE GENITALIA - TUMORS - Ovaries – cysts:

Apis Bov. Bufo canth. carb-an. Coloc. Iod. Kali-br.

Lach. merc. murx. Plat. prun. rhod. Rhus-t. thuj.

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GENITALIA - Female organs - swollen – ovaries: GRAPH. LACH.

GENITALIA - Female organs - swollen - ovaries [double]: Apis bufo nux-m.

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MURPHY REPERTORYMURPHY REPERTORY

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. 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.11/09/14 55

Pulse - FAST, pulse, elevated, exalted - ovarian cyst, in: Iod.

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

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SYSTHESIS REPERTORYSYSTHESIS REPERTORY

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.

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Therapeutical MedicinesTherapeutical Medicines

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Hedera helix (common lvy)

• Cystic ovaritis, especially on the left side.

• Amenorrhea in young girls. Infrequent menses.

• Menses late, shorter and less copious. Pre-menstrual leucorrhea.

• (Murphy)

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Cobaltum nitricum (nitrate of cobalt)

• Lack of libido. Metrorrhagia. Secondary amenorrhea.

• Cystic inflammation of the ovary. Sterility

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Hirudo medicinalis (leech) 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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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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Argentum metallicumArgentum metallicum

Hard, indurated, cystic ovaries, especially the left.

(FARRINGTON E. A., Comparative Materia Medica)

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Murex purpurea 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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BOVISTABOVISTA

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. 11/09/1466

APIS MELLIFICA

Mind -Apathy and indifference. Awkward; Listless; cannot think clearly. Jealous, fidgety, hard to please.

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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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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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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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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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. 11/09/1471

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

IODUMIODUMCongestion 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.

LILIUM TIGLILIUM TIGOvarian 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 MACULATUMCONIUM MACULATUMOvary enlarged, indurated, lancinating pain.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.

KALI BROMATUMKALI BROMATUMOvarian neuralgia with great nervous uneasiness. Cystic tumours of ovaries.Exaggerated sexual desire.Vomiting with intense thirst after each mealFidgety of hands, jerking and twitching o muscles.

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THANK YOUTHANK YOU

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