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Title: Polycystic ovarian disease by Dr.Shuchita chattree


1
Polycystic Ovarian DiseaseAnd Its Homoeopathy
approach
  • By Dr. Shuchita chattree
  • M.D. (PGR)
  • Department of Materia Medica
  • Homoeopathy University, Jaipur
  • Email shuchita.chattree_at_gmail.com

2
NORMAL OVARIES
  • Normal 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.

3
Ovary
4
Ovarian Attachments
  • 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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Histology
9
Ovary have 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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Cortex have following stage of developement
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  • 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
    ovulation
  • Produces progesterone, estrogens, relaxin and
    inhibin untill it degenerates into corpus
    albicans.

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  • Normal Female Reproductive cycle is divided into
    two phases
  • Ovarian phase
  • Uterine phase (Menstural cycle)

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  • Ovarian Cycle is divided into
  • Menstural phase (1st-5th day)
  • Pre-ovulatory phase. (5th-13th days)
  • Ovulatory phase. (13th-18th day)
  • Post-ovulatory phase. (18th 28th days)

Follicular phase
Ovalution
Luteal phase
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Histological appearance Of ovary tissues
during Female Reproductive cycle
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As we Magnifying it we sees
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Oocyte cell
31
Graafian follicle cell
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Secondary follicle cell
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Corpus Luteum
  • After 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.

34
Corpus Albicans
  • In the absence of fertilization the corpus luteum
    degenerates, decreases in size and form the
    corpus albicans which consists of dense
    connective tissue

35
How does cyst form???
36
  • In female reproductive cycle During follicular
    phase water starts accumulating around the egg
    cell.
  • Continuously size
  • increases as more water
  • accumulates.

37
Because of accumulation of water Follicle comes
to the periphery.
Release of ovum ovulation occurs
38
Remnants of the follicle called CORPUS LUTEUM.
If not fertilized, Menstruation occurs.
39
  • 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.

40
Cystic Oocyte
41
Polycystic 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 gt10 mL in at
    least one
  • ovary.

42
  • In The 2003 Rotterdam consensus workshop
    concluded that

PCOS is a syndrome of ovarian dysfunction along
with the cardinal feature of hyperandrogenism and
polycystic ovary morphology.
43
  • Epidemiology
  • Very prevalent disease affecting between 6.5 and
    8 of women overall.
  • Prevalence much higher in obese women (28 versus
    5.5).

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History
  • Originally described by Stein and Leventhal in
    1935, first known as the Stein-Leventhal
    syndrome
  • They saw in 7 women with amenorrhea, hirsutism,
    and obesity, found to have a polycystic
    appearance to their ovaries.
  • Insulin resistance described later by Burghen
    (1980)

46
ETIOLOGIES
  • 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)

47
Pathophysiology
48
  • Different Hypothesis
  • 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.

49
  • 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.

50
PATHOGENESIS
  • Polycystic ovaries develop when the 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).

51
  • This occur because of
  • 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 can result in
    increased free androgens.

52
Polycystic Ovaries
  • Chronic endocrine disorder resulting in
  • Insulin resistance
  • Hyperandrogenism
  • Altered gonadotropin functioning

53
Pathway Linking Hyperinsulinemia
Hyperandrogenemia
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OVARIAN STEROID BIOSYNTHETIC PATHWAY
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ABNORMALITIES OF PCOS OVARY
59
  • Increase activity in chromosome CYP17 region
    leads to increased p450c17 enzyme and hence
    increased androgen synthesis.

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Decrease in chromosomal region CYP19 activity
decreases aromatase enzyme activity and
conversion of androgens to E2 (Estradiol) is
reduced.
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  • 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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Hyperandrogen leads to altered Pituitary gonadal
axis.
66
Normal axis
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In PCOD
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  • Abnormal Pituitary FunctionAltered Negative
    Feedback Loop

hypothalamus
GnRH

Negative feed back effect blocked.
LH
pituitary
X
Androgens block inhibitory effect of progesterone
ovary
androgens
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Polycystic ovaries
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Clinical features
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  • Ovulatory dysfunction
  • Amenorrhea
  • Oligomenorrhea
  • Irregular uterine bleeding
  • Infertility

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  • Androgen excess
  • Hirsutism
  • Seborrhea

77
HIRSUTISM
78
Male Type Hair Growth on Abdomen-PCOS
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  • Androgen excess
  • Acne
  • Alopecia
  • Virilization.

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ALOPECIA
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ACNE
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  • Insulin resistance
  • Acanthosis nigricans.
  • Skin tags.
  • Obesity.

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Obesity
87
Acanthosis Nigricans
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Skin Tags
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DIAGNOSTIC CRITERIA
Vs
NIH
Rotterdam
92
PCOS Diagnostic criteria
  • Rotterdam (2003)
  • NIH (1990)
  • Menstrual Irregularity
  • Hyperandrogenism
  • Exclusion of other etiologies
  • 2 out of 3 required
  • Menstrual Irregularity
  • Hyperandrogenism
  • USG Polycystic ovary
  • Exclusion of other etiologies

93
  • Androgen Excess PCOS society Criteria 2006
  • Menstrual irregularity /- USG - Polycystic
    ovary.
  • Hyperandrogenism.
  • Exclusion of other etiologies

94
  • Diagnosis

95
  • Diagnosis
  • History-taking, specifically for menstrual
    pattern,
  • obesity, hirsutism, and the absence of breast
  • development.
  • BBT (basal body temperature)

96
  • 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 gt
    3 1
  • Laproscopic view

97
PCOS Evaluation
  • Biochemical evidence of hyperandrogenism
  • S. Total testosterone
  • USG evidence of Polycystic ovary
  • 12 or more follicles in each ovary measuring 2-9
    mm in diameter /- inc. ovarian volume (gt10 mL)
    Rotterdam criteria

98
USG view of Normal Uterus Ovaries.
99
USG view of Normal Ovary
100
USG view of PCOD Ovary
101
USG view of PCOD Ovary
102
PEARLY WHITE SMOOTH ENLARGED AND THICK WALLED
OVARY ON LAPROSCOPY ( PCOS)
103
  • Laparoscopy B/L polycystic ovaries are
    characteristic of PCOS.

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DIFFERENTIAL DIAGNOSIS
  • Late onset congenital adrenal hyperplasia
  • DHEAS (Dehydroepiandrosterone) gt 18mmol/l
  • 17 OH Prog (17 hydroxyprogestrone) gt 6 mmol/l
  • Ovarian adrenal androgen secreting tumours
  • Very high testosterone gt 6mmol/l

106
  • Cushings Syndrome
  • - Dexamethsone suppression test
  • - 24 hours urinary cortisol
  • - DHEAS (Dehydroepiandrosterone) gt 13 mmol/l
  • Iatrogenic and illegal androgen ingestion.
  • Hypothyroidisms (Thyroid profile test).
  • Hyperprolactinemia. (Serum Prolactine estimation)

107
Homoeopathic approach
108
  • Miasmatic Analysis

109
PCOD
psora
sycosis
tubercular
Psora initially brings about functional changes
in the form of neuro hormonal pathway leading to
hormonal changes.
syphilis
Sycotic miasm brings about pathological changes
in OVARIES leading to formation of CYSTS.
Tubercular miasm adds bleeding to the CYST.
Malignancy
110
  • Repertorial Analysis
  • Different Rubric given in
  • various Repertories

111
  • FEMALE GENITALIA - TUMORS - Ovaries cysts
  • Apis Bov. Bufo canth. carb-an. Coloc. Iod.
    Kali-br.
  • Lach. merc. murx. Plat. prun. rhod. Rhus-t.
    thuj.

Kent Repertory
112
  • GENITALIA - Female organs ovaries
  • Acon. agar. agn. Ambr. Ant-c. arn. Ars.
    ASAF. AUR. BELL.
  • calc. CANTH. CARB-AN. Carb-v. caust. Chel.
    CHIN. clem.
  • CON. dros. DULC. Graph. hyos. Ign. KALI-C.
    kali-n. LACH.
  • laur. LIL-T. LYC. MERC. Mez. nat-c. Nit-ac.
    Nux-v. pall. PLAT.
  • plb. puls. RAN-B. Ran-s. ruta SABIN. sars.
    SEC. SEP.
  • STAPH. Sulph. THUJ. ZINC.

BBCR Repertory
113
  • GENITALIA - Female organs - swollen ovaries
    GRAPH. LACH.
  • GENITALIA - Female organs - swollen - ovaries
    double Apis bufo nux-m.

BBCR Repertory
114
  • 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.

Murphy Repertory
115
  • 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.

Murphy Repertory
116
  • Pulse - FAST, pulse, elevated, exalted - ovarian
    cyst, in Iod.
  • Pulse - IRRITABLE, pulse - ovarian cyst,
  • in Iod.

Murphy Repertory
117
  • 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.

Synthesis Repertory
118
Some Rare Remedies for PCOD Given in different
Materia Medicas
119
  • Hedera helix (common lvy)
  • Female
  • Cystic ovaritis, especially on the left side.
  • Amenorrhea in young girls. Infrequent menses.
  • Menses late, shorter and less copious.
    Pre-menstrual leucorrhea.

-MURPHY R., Homeopathic Remedy Guide
120
  • Cobaltum nitricum (nitrate of cobalt)
  • Female
  • Lack of libido. Metrorrhagia. Secondary
    amenorrhea.
  • Cystic inflammation of the ovary. Sterility

-MURPHY R., Homeopathic Remedy Guide
121
  • Chlorpromazinum (largactil)
  • Female
  • Considerable leucorrhea like egg-white.
  • Amenorrhea.
  • Stretch-marks.
  • Sexual precocity.
  • Painful menses.
  • Cystic inflammation of the ovary.

-MURPHY R., Homeopathic Remedy Guide
122
  • Hirudo medicinalis (leech)
  • Female
  • 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.

123
  • Nepenthes distillatoria
  • Female
  • Stinging, needle-like, flashing pains around the
    right ovary in the morning.
  • Left ovarian pain, spreading to the left kidney.
    Menses early by 5 days and copious.
  • Menses repeat after a period of amenorrhea
    lasting 6 months.
  • Feeling of swelling of whole body 10 days before
    menses.
  • Cystic ovaritis.

124
Ovininum Ovary gland (Oophorinum)
  • Ovary has been suggested as a remedy in ovarian
    cysts.

125
  • 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
126
  • Robinia pseud-acacia, L
  • Swelling as if there were an ovarian cyst,
    especially in the left side of the abdomen.

ALLEN T. F., Encyclopedia of Pure Materia Medica
127
  • Argentum metallicum
  • Hard, indurated, cystic ovaries, especially the
    left.

FARRINGTON E. A., Comparative Materia Medica
(with therapeutic hints)
128
  • 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
129
The Important Common Homoeopathic drugs indicated
for Ovarian cysts are
  • Bovista
  • Apis mellifica
  • Platina
  • Lycopodium
  • Thuja
  • Lachesis

130
BOVISTA
  • 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.

131
APIS MELLIFICA
  • Mind -Apathy and indifference. Awkward drops
    things readily. Listless cannot think clearly.
    Jealous, fidgety, hard to please. Sudden shrill,
    piercing screams. Whining.
  • 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.

132
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

133
Lycopodium
  • Vagina dry, painful coition.
  • Varicose veins of pudenda.
  • Leucorrhoea acrid with burning in vagina.
  • Discharge of blood from vagina during stool.
  • Melancholy afraid to be alone.

134
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.

135
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.

136
Bufo
  • Burning heat and pain in the ovaries which
    extends down the thigh.
  • Dysmenorrhoea with cysts and hydatids about
    ovaries.

137
Iodum
  • Congestion 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.

138
Lilium Tig.
  • Ovarian 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.

139
Conium Mac.
  • Ovary enlarged, indurated, lancinating pain.
  • Ovaritis
  • 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.

140
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.

141
Kali Bromatum
  • Ovarian neuralgia with great nervous uneasiness.
  • Cystic tumours of ovaries.
  • Exaggerated sexual desire.
  • Vomiting with intense thirst after each meal
  • Fidgety of hands, jerking and twitching o
    muscles.

142
Other Rare drugs indicated for Ovarian cyst
  • Oophorinum
  • Aur. Iod.
  • Xantoxylum

143
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