Miss XYZ, 27 years old, conceived soon after marriage. Incidental diagnosis of endometriosis was made during her caesarean section. She had an unplanned pregnancy soon after, which she aborted. Two years later, when she was unable to conceive, she was diagnosed to have a recurrence of endometriosis causing blockage of both tubes, and she had to undergo IVF to conceive again...READ MORE
Polycystic Ovarian Syndrome (PCOS) is a condition where too many eggs start forming in the ovaries, but none of these reaches maturation. This leads to irregular menses & hormonal imbalance & even difficulty in conceiving...READ MORE
Fibroids (aka myoma) are non-cancerous tumours that develop in and around the uterus. They are basically lumps of uterine muscle and fibrous tissue which may be of various size...READ MORE
Miss XYZ, 27 years old, conceived soon after marriage. Incidental diagnosis of endometriosis was made during her caesarean section. She had an unplanned pregnancy soon after, which she aborted. Two years later, when she was unable to conceive, she was diagnosed to have a recurrence of endometriosis causing blockage of both tubes, and she had to undergo IVF to conceive again.
Miss ABC was diagnosed to have endometriosis at the age of 19 years due to painful periods. Later she underwent laparoscopy due to infertility but was still not able to conceive. After seven years of marriage, she finally conceived with IVF and was blessed with a baby girl. One year later, she had a spontaneous pregnancy & was blessed with a baby boy. So, no two cases of endometriosis are the same. Let us know more about this enigmatic disease through a series of questions & answers.
It is a condition in which tissue similar to the uterine lining develops in organs other than the uterus (most commonly ovaries and fallopian tubes but can occur anywhere). This tissue bleeds during menstruation just like the uterine lining, causing collection of blood (called cysts or endometriosis). This also leads to inflammation and formation of bands of scar tissue called adhesions. Approximately 30% of infertile women & 70% of women with chronic pelvic pain are diagnosed to have endometriosis.
The most common symptoms are painful periods, painful intercourse & inability to conceive. Generalized abdominal pain, painful defecation or urination (especially during periods) may occur. Sometimes heavy or irregular periods may be present.
The symptoms and signs elicited during the examination will usually give a clue. Diagnosis is usually made with ultrasound, especially if cysts are present. Rarely MRI may be required to make a diagnosis. Sometimes laparoscopy has to be done to confirm the diagnosis and treat it at the same time.
Definitely not Painful periods can be just incidental or may be due to other reasons such as infections or fibroids.
About 1/3rd women with endometriosis conceive naturally; sometimes, the diagnosis is made incidentally during surgery done for another reason. Infertility occurs when cystic collections of blood or adhesions form in/around the ovaries or tubes preventing the escape of eggs from the ovaries or their transport by the tubes to the uterus. The inflammatory changes in the pelvis can themselves interfere with fertilization.
Treatment:-There are two different problems that need to be dealt with pain and infertility. Pain frequently responds well to various hormonal treatments. However, these hormonal treatments lead to suppression of ovulation and cannot be given to women desiring fertility. Pain that does not respond to medicines will need surgical treatment. Frequently medication will have to be continued after surgery. Fertility is affected by endometriosis usually requires intervention in the form of surgery or IVF(In Vitro Fertilization) Surgical treatment is best performed laparoscopically (key-hole surgery) and involves the removal of cysts and scar tissue (adhesions). If however the disease is extensive (stage 3 or 4) or the woman does not conceive after surgery, IVF is the best option. In older women also, IVF is preferred over surgery due to inherent shrinkage of the ovaries because of ageing and endometriosis. Most women with endometriosis do well with IVF.
Risk of Cancer:- Endometriosis is very rarely associated with cancer. However women with Endometriosis has a marginally increased lifetime risk of cancer than women without endometriosis.
Polycystic Ovarian Syndrome (PCOS) is a condition where too many eggs start forming in the ovaries, but none of these reaches maturation. This leads to irregular menses & hormonal imbalance & even difficulty in conceiving. The multiple eggs which are forming in the ovaries appear like tiny bubbles or cysts—hence the name polycystic ovaries. These cysts are not tumours. Normal ovary Vs PCOS Ultrasonographic Normal ovary Vs PCOS
Some of the reasons that may give complications are:Irregular periods occur in most but not all women. Increased male hormone level in these women can cause excessive unwanted hair growth (hirsutism) over the face, chest, abdomen, etc. Acne & hair loss with male pattern baldness are also manifestations of this hormonal imbalance.
There are three important features of PCOS:-
1. Irregular periods
3. Ultrasonographic appearance of multiple small follicles arranged along the periphery of the ovaries.
If any two or all three features are present, a diagnosis of PCOS is made. Other causes of irregular periods must be ruled out, such as Hypothyroidism & increased level of hormone Prolactin. If hirsutism is excessive, assessment for other causes must be done, such as Congenital Adrenal Hyperplasia (CAH) or Androgen Secreting Tumors.
The incidence of PCOS is definitely on the rise. This increase is associated with increasing obesity & poor lifestyle (decreased physical activity, intake of diet rich in carbohydrates & fats and poor in fibre). Obesity, however, is not a cause of PCOS. Only 50% of women with PCOS are obese. Obesity does increase the manifestations of PCOS. Also, women predisposed to develop PCOS may develop symptoms when they put on weight. PCOS is also over-diagnosed in young girls. In the adolescent age group, ultrasonography will show multiple follicles in the ovaries in most girls. This should not be considered a criterion for diagnosing PCOS in this age group. Unfortunately, too many young girls are being labelled as having PCOS based on ultrasound findings. This then becomes an excuse for not losing weight. More weight gain then continues to worsen the problem.
The basic abnormality is Insulin Resistance (IR), i.e. the body is not responsive to the normal level of insulin. As a result, the body secretes excessive insulin (HyperInsulinemia or HI) & this is responsible for the development of various manifestations of PCOS. Obesity per person is not a cause of PCOS, but it increases the IR & HI. That is why weight gain offsets the symptoms of PCOS in a lot of women who have underlying IR.
There is a genetic predisposition to PCOS (Polygenic Inheritance) with familial aggregation.
In fact, it is the other way round; obesity increases the chances of having PCOS. Once weight gain occurs, it may, however, be difficult for these women to lose weight.
Fertility in these women depends upon the severity of the problem, i.e. how irregular the periods are & also the presence of obesity.
- Menstrual Irregularity & Fertility:- Weight reduction is the mainstay of treatment. Even 50% weight loss in overweight women leads to improvement in menstrual regularity & fertility. Combined Oral Contraceptives Pills (Birth Control Pills) on the advice of a doctor is the first line of medical management in women not planning a pregnancy. Use of Birth Control Pills is very safe, even in most young girls. In most women who are not being able to conceive, simple oral medications can give results. Sometimes gonadotropin injections may be required, which may be combined with IUI (Intrauterine Insemination) Laparoscopic Ovarian Drilling (LOD) is a procedure in which some of the cysts in the ovaries are burnt with a needle using electric current. It should be used only selectively, and It is more useful in thin, lean women with PCOS. IVF (Test Tube Baby) Women who do not conceive with routine medication & IUI may need to undergo IVF. Also, IVF is preferable in older women & if there is a problem in the fallopian tubes & husbands semen. Results of IVF are inversely proportional to the female partner’s weight & age as well as the sperm quality. Marked improvement in the result of IVF is seen if overweight women reduce their weight.
- For unwanted facial hair/body hair medications are available. These, however, can reduce the coarseness of the hair & rate of growth & to some extent prevent newer hair follicles. Permanent removal of already present hair requires physical measures such as laser treatment or electrolysis. The mainstay of treatment remains lifestyle modification & weight loss. Medicines like Metformin & Myo Inositols have a limited role.
It can be treated & kept under control with a good lifestyle.
The chances of high blood pressure & diabetes in pregnancy along with their related complications are increased —such as preterm delivery, low birth weight, sometimes overweight babies with a difficult delivery, increased chance of Cesarean Section, etc.
Yes, women with PCOS are more likely to develop Diabetes, High Blood Pressure, High Cholesterol, Ischemic Heart Diseases (Heart Attack) etc. These problems are more likely to occur in women who have PCOS and are overweight. Also, there is a 2-6 fold increase in the risk of endometrial carcinoma (Uterine Cancer) & it occurs at a younger age.
People have to be sensitized to the problems associated with obesity. Obesity has to be prevented right from childhood by proper awareness, diet control & regular exercise. This will reduce the manifestation of PCOS & all its complications.
Fibroids (aka myoma) are non-cancerous tumours that develop in and around the uterus. They are basically lumps of uterine muscle and fibrous tissue which may be of various size.
Fibroids are very common; around 50 per cent of women develop fibroids at some point in their life. They develop only after menstruation starts & shrink after menopause.
About 2/3 women with fibroids have no symptoms--- Symptoms (when present) depend on their location & size.
1. Submucosal Fibroids are those which grow towards the uterine cavity. They cause heavy & painful periods, even when quite small. They also interfere with fertility.
2. Intramural Fibroids are those which grow within the uterine wall & cause similar symptoms but only when they are quite large in size or multiple in number. Due to uterine enlargement, they can cause pressure symptoms such as frequent urination due to pressure on the bladder and constipation due to pressure on the rectum.
3. Subserosal fibroids are those which grow outwards. They are usually asymptomatic but may also cause pressure symptoms. Twisting of pedunculated subserosal fibroids or degeneration of any type of fibroid can cause severe abdominal pain.
Submucosal fibroids interfere with fertility even when quite small. Intramural fibroids can cause problems when they are large in size or multiple in numbers, due to interference in the blood flow and contractility of the uterus. Subserosal fibroids may cause infertility by distorting the cervix or fallopian tubes. In these situations, surgical removal of fibroids is required.
Most women will have no ill-effects of fibroids on their pregnancy. In 10-30%, complications can occur, such as pain abdomen due to degeneration of the fibroids, fetal growth restriction, miscarriage, pre-term delivery, caesarean section, etc.
Most fibroids do not need surgery. Fibroids need no treatment if they do not cause any symptoms. If symptoms are present, most of the time, medications can provide relief. Those who are not relieved do well with surgical removal of the fibroids/uterus.
Medicines/Injections are available to shrink fibroids, but they have a temporary benefit only. They are used only in unusual situations to buy time. For example, in women unable to conceive and having fibroids causing only slight distortion of the uterine cavity, or women who have a recurrence of fibroids after previous surgical removal (since repeated surgeries are risky). In symptomatic premenopausal women also medicines can be given to shrink the fibroids temporarily and after menopause, they will shrink further.
In women who are yet to complete their families, obviously, removal of the fibroids (myomectomy) is the preferred option. However, there is always a risk of reappearance of fibroids, especially if they are multiple in numbers. Removal of the uterus (Hysterectomy)is a much simpler and less risky surgery and is preferred in women who are older & have completed their families.
Keyhole surgery has advantages of less blood loss, less pain and faster recovery but it must be performed by an expert surgeon.
Cancer in fibroids is very very rare(less than 1 in 1000). Fibroids that grow rapidly, especially after menopause, are likely to be cancerous.