Female complaints

PCOS

Polycystic ovarian syndrome (PCOS) is a syndrome manifested by amenorrhea, hirsutism and obesity associated with enlarged polycystic ovaries. This heterogeneous disorder is characterized by excessive androgen production by the ovaries mainly.

Diagnosis is based upon the presence of any two of the following three criteria (ASRM/ESHRE, 2003).
• Oligo and/or anovulation.
• Hyperandrogenism (clinical and/or biochemical).
• Polycystic ovaries.
Other etiologies (CAH, thyroid dysfunction, hyperprolactinemia, Cushing syndrome) are to be excluded.

The patient complains of increasing obesity (abdominal – 50%), Menstrual abnormalities (70%) in the form of oligomenorrhea, amenorrhea or DUB and infertility. Presence of hirsutism and acne are the important features (70%). Virilism is rare. Acanthosis nigricans is characterized by specific skin changes due to insulin resistance. The skin is thickened and pigmented (grey brown). Commonly affected sites are nape of the neck, inner thighs, groin and axilla. HAIR-AN syndrome in patients with PCOS is characterized by:
1. Hyperandrogenism,
2. insulin resistance
3. Acanthosis nigricans.
Internal examination reveals bilateral enlarged cystic ovaries which may not be revealed due to obesity. Sonography — Transvaginal sonography (TVS) is specially useful in obese patient.

LH level is elevated and/or the ratio LH: FSH is > 2:1. Raised level of estradiol and estrone. SHBG level is reduced. Raised serum testosterone (> 150 ng/dl) and DHEA–S may be marginally elevated.

Raised fasting insulin levels > 25 μIU/ml and fasting glucose/insulin ratio < 4.5 suggests IR (50%). Levels of serum insulin response > 300 μIU/ml at 2 hours postglucose (75 gm) load, suggests severe IR. Features suggestive of insulin resistance are: BMI > 25 kg/m2, Acanthosis nigricans and Waist to hip ratio > 0.85.
In about 20% cases, there may be mild elevation of prolactin level due to increased pulsitivity of GnRH or due to dopamine deficiency or both. The prolactin further stimulates adrenal androgen production.

Obesity is also associated with reduced SHBG. It also induces insulin resistance and hyperinsulinemia which in turn increases the gonadal androgen production.

Risk of hypertension and cardiovascular disease as dyslipidemia (↓HDL,↑triglycerides, ↑LDL) is the most common metabolic abnormality in women with PCOS. Obsructive sleep apnea.



FIBROID
Fibroid is the commonest benign solid tumor in female. It has been estimated that at least 20 percent of women at the age of 30 have got fibroid in their wombs. Fortunately, most of them (50%) remain asymptomatic. The incidence of symptomatic fibroid in hospital outpatient is about 3 percent. These are more common in nulliparous or in those having one child infertility. The prevalence is highest between 35–45 years.

The aetiology still remains unclear. The prevailing hypothesis is that, it arises from the neoplastic single smooth muscle cell of the myometrium, chromosomal abnormality, Role of polypeptide growth factors—Epidermal growth factor (EGF), insulin-like growth factor-1 (IGF-1), transforming growth factor (TGF), stimulate the growth of leiomyoma either directly or via oestrogen. A positive family history is often present.

It is predominantly an estrogen-dependent tumor. Estrogen and progesterone is incriminated as the cause. Estrogen dependency is evidenced by growth potentiality is limited during childbearing
Period, increased growth during pregnancy, they do not occur before menarche, following menopause, there is cessation of growth
and there is no new growth at all, It seems to contain more estrogen receptors than the adjacent myometrium, Frequent association of anovulation.

The growth potentiality is not squarely distributed amongst the fibroids which are usually multiple, some grow faster than the others. On the whole, the rate of growth is slow and it takes about 3–5 years for the fibroid to grow sufficiently to be felt per abdomen.

However, the fibroid grows rapidly during pregnancy or amongst pill users (high dose pills). Rapid growth may also be due to degeneration or due to malignant change. The newer low dose oral contraceptives are not associated with increase in the growth of a fibroid. The fibroids are mostly located in the body of the uterus and are usually multiple.

Menorrhagia (30%) is the classic symptom of symptomatic fibroid.
The menstrual loss is progressively increased with successive cycles. Increased surface area of the endometrium (Normal is about 15 sq cm). Interference with normal uterine contractility due to interposition of fibroid. Congestion and dilatation of the subjacent endometrial venous plexuses caused by the obstruction of the tumor.

Symptoms of Fibroid Uterus
Asymptomatic—majority (75%)
Menstrual abnormality: Menorrhagia, metrorrhagia
Dysmenorrhea
Dyspareunia
Infertility
Pressure symptoms
Recurrent pregnancy loss (miscarriage, preterm labor)
Lower abdominal or pelvic pain
Abdominal enlargement

Pregnancy-related problems like abortion, preterm labor and intrauterine growth restriction are high. The reasons are defective implantation of the placenta, poorly developed endometrium, reduced space for the growing fetus and placenta.

The fibroids are usually painless. Pain may be due to tumor Degeneration, torsion subserous pedunculated fibroid, extrusion of polyp or due to associated pelvic pathology.

The patient may have a sense of heaviness in lower abdomen. She may feel a lump in the lower abdomen even without any other symptom.

Pressure symptoms are rare in body fibroids. The fibroids in the posterior wall may be impacted in the pelvis producing constipation, dysuria or even retention of urine.

General examination reveals varying degrees of pallor depending upon the magnitude and duration of menstrual loss.

The fibroid of varying sizes may be confused with: (1) Pregnancy (2) Full bladder (3) Adenomyosis (4) Myohyperplasia (5) Ovarian tumor (6) TO mass.