PCOD, Poly Cystic Ovarian Disease

Clinic

• PCOS is the most common endocrine disorder in women of reproductive age.
• It is named after the characteristic cysts which may form on the ovaries. Cyst is a symptom and not the underlying cause of the disorder.
• They may experience irregular menstrual periods, heavy periods, excess hair, acne, pelvic pain, difficulty getting pregnant, and patches of thick, darker, velvety skin.
• Prevalence of PCOS could be as high as 26% among some populations, though ranges between 4% and 18% are reported for general populations.
• The exact cause of PCOS remains uncertain and there is no known cure.

Primary characteristics

1. Hyperandrogenism
2. Anovulation
3. Insulin resistance
4. Neuroendocrine disruption

Signs / Symptoms

• Menstrual disorders: Mostly oligomenorrhea or amenorrhea , but other types of menstrual disorders may also occur.
• Infertility: Due to chronic anovulation (lack of ovulation).
• Hyperandrogenism: The most common signs are Acne and hirsutism, but it may produce hypermenorrhea, androgenic alopecia, or other symptoms. (Prevalence 75%)
• Metabolic syndrome: Central obesity + Other symptoms of insulin resistance including low energy levels and food cravings. Serum insulin, insulin resistance, and homocysteine levels are high
• Polycystic ovaries in sonography

Note

• It seems that PCOS belongs to Central / Secondary Hypogonadotropic Hypogonadism.
• It means that at least Anovulatory type of PCOS is related to Hyper Prolactin secretion, which ends in GnRH/ FSH / LH suppression
• Finally Estrogen, Progesterone fall down which leads in Hyper androgenism and Anovulation
• Note that most of Sign / Symptoms of PCOS are Post- Nodes, Since they are consequents of hormonal changes. Therefore we should have two different stategies one for hormonal changed consequents and the other for stating point of disease which may be a dynamic miasm.
• Dr Dhanipkar suggest a sarcode in order to solve the physiologic consequents hormonal imbalances
  • Testosterone for Hyperandrogenism of PCOS. They have Hirsutism, Androgenic alopecia, Deepening of the voice, Clitoromegaly, Acne and Menstrual problems, Weight gain, Menstrual irregularities, Acanthosis nigricans, and Insulin resistance
  • Thyroidinum for Hypothyroidism, which can not only worsen the symptoms of PCOS (including weight gain, irregular periods, and increased insulin resistance) but it can cause symptoms not commonly seen with PCOS. These include Goiters, Facial mooning, and Bradycardia
• There are three Hypogonadism, Primary, Secondary and third one .
• Primary hypogonadism refers to oophoritis, therefore we should find some inflamatory signs such as painful menses or AUB. This would be probably causation of some of cases of OCOS
• Secondary Hypogonadism is not

PCOS types	Menses delay	Obesity	Fatigue	Androgen	Insulin	DHEAS	Miams
Insulin resistant	+++	+++	+++	+++	+++
Adrenal		+++	+++	---	---	+++
Inflammatory		+++

1- Insulin resistant PCOS

• This is the most common type of PCOS (70%)
• Hyperinsulinemia (Fasting insulin rising, Normal fasting insulin levels are less than 10 mIU/L (60 pmol/L).
• Holding weight around Stomach/ Abdomen
• Sugar cravings (FBS, HbA1c)
• Fatigue / Brain fog
• High levels of androgen (Excess hair, Male pattern hair loss, Acne)

2- Post-pill PCOS

Post-pill PCOS occurs in some people after they stop taking the oral contraceptive pill.

• Acne
• Irregular periods
• Excess hair growth were not present prior to starting the pill at all.
• Oral contraceptives such as Ginet, Yasmin and Yaz are often involved in this type of PCOS due to the type of synthetic progestins used.
• After coming off the pill, your ovaries basically throw a party and there is a natural surge in androgens which can cause typical PCOS symptoms
• But there is no insulin resistance

3- Adrenal PCOS

• This type of PCOS is due to an abnormal stress response and affects around 10% of those diagnosed.
• Typically DHEA-S (another type of androgen from the adrenal glands) will be elevated alone
• High levels of testosterone and androstenedione are not seen.
• This type of androgen unfortunately isn’t often tested, unless you go through an endocrinologist or other specialist.

• High DHEAS levels are found in 22–25% of patients with PCOS. However, some studies have reported frequencies of DHEAS levels as high as 48–52% in PCOS. Another finding is that patients with high DHEAS levels are younger, thinner, and more hirsute than PCOS patients with normal DHEAS levels.
• CFS and Cushing have also raised DHEAS levels.

4- Inflammatory PCOS

• In inflammatory PCOS, chronic inflammation causes the ovaries to make excess testosterone, resulting in physical symptoms and issues with ovulation.
• Signs of inflammation include headaches, joint pain, unexplained fatigue, skin issues like eczema and bowel issues like IBS.
• Typically, you will see raised inflammatory markers on a blood test, such as a high CRP above 5.
• Other tests such as fasting glucose and insulin are in the normal range, but can sometimes be affected as inflammation can affect these numbers.
• Miasms: MMP, HSV-1, HSV-2

Miasmatic review

• Inflammatory PCOS should be considered as primary hypogonadism, therefore its best entity would be Oophoritis. So there id only one miasm, which is MMP.
• Insulin resistant and Adernal PCOS , which contains 90% f cases, have Amenorrhea and Androgenic Sign / Symptoms due to different cause. Insulin resistance PCOS have Hyper androgenism due to hyper insulinemia and Adrenal PCOS due to Adrenal Hyperactivity due to abnormal stress response (cortisol hyper secretion). Although they could be diagnosed para clinically, but not clinically. Both could be classified as secondary / Tertiary hypogonadism.
• Secondary hypogonadism could be the result of Hypophysitis, while its only miasm is MTB.
• Tertiary hypogonadism could be the result of Hypothalamus hyperactivity in secreting GnRH. This is would be the result of Insulin resistance (TBIR)
  • Female, infertility
  • Depression, Fatigue
  • Alopecia: Here we have HCV miasm, which emphasize on Endocrinologist effect of it
  • Gynecomastia: It has exactly opposite situation in men. While PCOS has decreased estrogen / Increased Androgen in women, Gynecomastia has increased estrogen / Decreased Androgen in men
  • Insulin resistance, (TBIR)

Briefly saying

MMP candidates for inflammatory PCOS, HCV for Insulin resistance PCOS

Related disease

• Type 2 diabetes
• Obesity
• Obstructive sleep apnea
• Heart disease
• Mood disorders
• Endometrial cancer
• Ovarian Cyst

Women with PCOS tend to have central obesity, but studies are conflicting as to whether visceral and subcutaneous abdominal fat is increased, unchanged, or decreased in women with PCOS relative to reproductively normal women with the same body mass index. In any case, androgens, such as testosterone, androstanolone (dihydrotestosterone), and nandrolone decanoate have been found to increase visceral fat deposition in both female animals and women.

Although 80% of PCOS presents in women with obesity, 20% of women diagnosed with the disease are non-obese or "lean" women. However, obese women that have PCOS have a higher risk of adverse outcomes, such as hypertension, insulin resistance, metabolic syndrome, and endometrial hyperplasia.

Even though most women with PCOS are overweight or obese, it is important to acknowledge that non-overweight women can also be diagnosed with PCOS. Up to 30% of women diagnosed with PCOS maintain a normal weight before and after diagnosis. "Lean" women still face the various symptoms of PCOS with the added challenges of having their symptoms properly addressed and recognized. Lean women often go undiagnosed for years, and usually are diagnosed after struggles to conceive. Lean women are likely to have a missed diagnosis of diabetes and cardiovascular disease. These women also have an increased risk of developing insulin resistance, despite not being overweight. Lean women are often taken less seriously with their diagnosis of PCOS, and also face challenges finding appropriate treatment options. This is because most treatment options are limited to approaches of losing weight and healthy dieting.

Testosterone levels are usually elevated in women with PCOS. In a 2020 systematic review and meta-analysis of sexual dysfunction related to PCOS which included 5,366 women with PCOS from 21 studies, testosterone levels were analyzed and were found to be 2.34 nmol/L (67 ng/dL) in women with PCOS and 1.57 nmol/L (45 ng/dL) in women without PCOS. In a 1995 study of 1,741 women with PCOS, mean testosterone levels were 2.6 (1.1–4.8) nmol/L (75 (32–140) ng/dL). In a 1998 study which reviewed many studies and subjected them to meta-analysis, testosterone levels in women with PCOS were 62 to 71 ng/dL (2.2–2.5 nmol/L) and testosterone levels in women without PCOS were about 32 ng/dL (1.1 nmol/L). In a 2010 study of 596 women with PCOS which used liquid chromatography–mass spectrometry (LC–MS) to quantify testosterone, median levels of testosterone were 41 and 47 ng/dL (with 25th–75th percentiles of 34–65 ng/dL and 27–58 ng/dL and ranges of 12–184 ng/dL and 1–205 ng/dL) via two different labs. If testosterone levels are above 100 to 200 ng/dL, per different sources, other possible causes of hyperandrogenism, such as congenital adrenal hyperplasia or an androgen-secreting tumor, may be present and should be excluded.

Associated conditions

Warning signs may include a change in appearance. But there are also manifestations of mental health problems, such as anxiety, depression, and eating disorders.^{[medical citation needed]}

A diagnosis of PCOS suggests an increased risk of the following:

• Endometrial hyperplasia and endometrial cancer (cancer of the uterine lining) are possible, due to overaccumulation of uterine lining, and also lack of progesterone, resulting in prolonged stimulation of uterine cells by estrogen. It is not clear whether this risk is directly due to the syndrome or from the associated obesity, hyperinsulinemia, and hyperandrogenism.
• Insulin resistance/type 2 diabetes. A review published in 2010 concluded that women with PCOS have an elevated prevalence of insulin resistance and type 2 diabetes, even when controlling for body mass index (BMI). PCOS is also associated with higher risk for diabetes.
• High blood pressure, in particular if obese or during pregnancy
• Depression and anxiety
• Dyslipidemia – disorders of lipid metabolism – cholesterol and triglycerides. Women with PCOS show a decreased removal of atherosclerosis-inducing remnants, seemingly independent of insulin resistance/type 2 diabetes.
• Cardiovascular disease, with a meta-analysis estimating a 2-fold risk of arterial disease for women with PCOS relative to women without PCOS, independent of BMI.
• Strokes
• Weight gain
• Miscarriage
• Sleep apnea, particularly if obesity is present
• Non-alcoholic fatty liver disease, particularly if obesity is present
• Acanthosis nigricans (patches of darkened skin under the arms, in the groin area, on the back of the neck)
• Autoimmune thyroiditis^{[citation needed]}
• Some studies report a higher incidence of PCOS among transgender men (prior to taking testosterone), though not all have not found the same association. People with PCOS in general are also reportedly more likely to see themselves as "sexually undifferentiated" or "androgynous" and "less likely to identify with a female gender scheme."

The risk of ovarian cancer and breast cancer is not significantly increased overall.

Cause

• PCOS diagnosis is based on two of the following three findings:
  1. Anovulation
  2. High androgen levels
  3. Ovarian cysts
• Other conditions that produce similar symptoms include
  1. Adrenal hyperplasia
  2. Hypothyroidism
  3. High blood levels of prolactin

Pathogenesis

• PCOS develops when ovaries are stimulated to produce excessive amounts of testosterone, by either one or a combination of the following:

1. Excessive LH by anterior pituitary
2. High levels of insulin (Hyperinsulinaemia)

A majority of women with PCOS have insulin resistance and/or are obese, which is a strong risk factor for insulin resistance, although insulin resistance is a common finding among women with PCOS in normal-weight women as well.

• Elevated insulin levels could cause Hypothalamic–pituitary–ovarian axis abnormalities that lead to PCOS.
• Hyperinsulinemia increases GnRH pulse frequency, which in turn results in an
  • Increase in LH/FSH ratio , increased ovarian androgen production;
  • Decreased follicular maturation; and
  • Decreased SHBG binding.
  • Increases the activity of 17α-hydroxylase, which catalyzes the conversion of progesterone to androstenedione, which is in turn converted to testosterone.
• The combined effects of hyperinsulinemia contribute to an increased risk of PCOS.

Adipose (fat) tissue possesses aromatase, an enzyme that converts androstenedione to estrone and testosterone to estradiol. The excess of adipose tissue in obese women creates the paradox of having both excess androgens (which are responsible for hirsutism and virilization) and excess estrogens (which inhibit FSH via negative feedback).

The syndrome acquired its most widely used name due to the common sign on ultrasound examination of multiple (poly) ovarian cysts. These "cysts" are in fact immature ovarian follicles. The follicles have developed from primordial follicles, but this development has stopped ("arrested") at an early stage, due to the disturbed ovarian function. The follicles may be oriented along the ovarian periphery, appearing as a 'string of pearls' on ultrasound examination.

PCOS may be associated with chronic inflammation, with several investigators correlating inflammatory mediators with anovulation and other PCOS symptoms. Similarly, there seems to be a relation between PCOS and an increased level of oxidative stress.

Remedies

		Female / Genital symptoms	Other symptoms
Top Remedy	Puls	Puls is the second remedy. But it dose not act permanently and should be accompanied with other remedies esp Lyc PCOS with very less and late menses. Extremely Suppressed Menses Menses is very scanty and extremely painful. Young girls at puberty who suffer from PCOS with irregular menses.	Total absence of thirst /Desire for cool open air which amel her. Mild, sensitive nature with weeping tendencies She weeps at the slightest instance and feels somewhat better when given consolation.
Irregular Periods, Facial Hair And Pigmentation	Sep	PCOS with acute pains. It occupies the top position among others Menses is late and scanty Bearing down sensations in the pelvic region Ovaries remain enlarged with fluid-filled cysts in them. Infertility cases due to PCOS Abnormal hair growth on the face, esp on upper lip	Sensitivity to cold air Mental irritability Indifferent behavior towards loved ones.
Weight Gain And Heavy Period	Calc	For Prolonged and Profuse menses Weight gain and obesity Excessive sweating on the head Extreme sensitivity to cold air	Peculiar craving in eating habits like a desire for boiled eggs and in a few cases Desire for strange things like chalk and lime.
Hair Fall And Hair Thinning	Nat-m	PCOS with Irregular and Suppressed Menstrual Cycles Difficulty in conception due to PCOS	Hot sensation, aversion to sun heat Craving for extra salt in the diet Reserved people Weeping spells esp when alone Agg when sympathy is offered.
Acne (Pimples)	Hep	Esp Pustular acne These are attended with a prickling pain. Sometimes blood may ooze from pimples.
Hair Growth On Face	Ol-j	Esp on chin or upper lip. The hair may be thick.
Late By Several Months	Kali-c	Absence of menses for several months	When periods come, they are heavy in nature. It is attended with backache. Before periods, a colicky pain in lower abdomen may be felt.
Hair Growth On Face And Skin pigmentation	Thuj	Remedy of large complication of hormonal imbalance esp on skin such as Acne, hirsutism and greasy skin. For Retarded Menstrual Flow + Multiple cysts in ovaries Abnormal growth or accumulation anywhere in the body such as cysts	Esp on left-side ovary Extreme hair growth on unusual parts in women due to hormonal imbalance
Metabolic syndrome	Lyc	In my experience, Lyc is very effective, esp in chronic cases, who have other endocrinological problems such as Hypothyroidism, Adrenal insufficiency and Non-alcoholic fatty liver disease
Big, painful ovarian cyst	Apis	Stinging/ Pricking pain in ovaries or a tender uterine/abdominal area Esp agg after sexual intercourse Swelling of abdominal area	Sensitive to heat
Sensitive to prssure	Lach	Absence of menses for several months Short / Feeble menses Abdomen pain before your menses	Tight clothes agg

Repertory

Sign / Symptoms	Remedies
Suppressed / Absent Menses	Puls, Kali-c and Senec Menses suppressed complaints such as heaviness or pain in the pelvic region and nausea.
Scanty /Short Menses	Puls, Sep and Senec Vary from a few hours to one or two days. For menses remaining only for a few hours: Euphr, Cocc, and Psor Sep and Puls can help for menses of one-day duration.
Irregular Menstrual Cycle	Nat-m, Puls, Sep
Hirsutism	Sep is preferred if there is hair growth on upper lips. For hair growth on the chin, Ol-j is best Thuj is a medicine of great help for excessive hair growth anywhere on the body, face, arms and legs.
Acne /Pimples	Sul and Sil Sul is the best choice in Painful/ Itching. Sil in Cystic Acne (Pus formation)
Obesity	Calc, Graph and Am-c
Ovarian Cysts in PCOS	Right ovary: Lyc, Bell and Apis In left ovary cysts, Thuj and Lach
Constipation	Graph: PCOD with