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Endometriosis and Polycystic Ovarian Syndrome (PCOS)

Endometriosis and Polycystic Ovarian Syndrome (PCOS)

The Question

Polycystic Ovarian Syndrome

Endometriosis

Medications Associated with PCOS

Management of Endometriosis and PCOS

Conclusion

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The Question: "I have been diagnosed with polycystic ovary disorder and endometriosis. I have dealt with surgery, infertility, pain and frustration. The newest challenge facing me is if I should take Lupron or not. I have tried BCP all types unsuccessfully because I do not tolerate them well. My stomach neither does nor handles medications well. Now they have put me on Prometrium to induce a period and I am finding that after three days it is causing the same stomach pain as Yasmin did. My first question is would Lupron cause similar symptoms and is there is a herb or homeopathic medicine that could help. "... "


Dr. Keti:
December 28, 2003

Polycystic Ovary Syndrome
According to some research, Polycystic Ovary Syndrome (PCOS) may affect from 6% to 10% of women. Reproductive endocrine disorders in women are associated with this syndrome. Additionally, the cause may be linked to metabolic problems with insulin and some studies show that it is strongly linked to women who are overweight (1).
Typical symptoms may include irregular periods, pain, high blood pressure, acne, obesity and in putting on weight especially around waist, male-pattern baldness and hirsutism or excessive body hair. The metabolic syndrome of hypertension, diabetes, and central obesity referred as the Stein-Leventhal syndrome is believed to be associated with polycystic ovaries. You can read more on PCOS on this web site: PCOS Frequently Asked Questions
According to one article "Insulin resistance, higher serum triglyceride levels, and lower High-Density Lipoprotein(HDL) cholesterol levels commonly occur in women with polycystic ovaries." These factors may contribute to a higher incidence of coronary artery disease in women.
Women with PCOS are at risk for developing diabetes mellitus type 2, hypertension, intravascular thrombosis, coronary artery disease, and endometrial cancer. (2)

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Endometriosis is another common gynecological disorder associated with infertility. Endometriosis affects many women during the reproductive years. It is estimated that endometriosis affects up to 20% of pre menopausal women in the US. Endometriosis, occurs when tissue like the one lining the inside of the uterus, known as endometrium, grows outside the womb in other places and on other organs of the woman's body. This tissue is often referred as ectopic (outside the place or topos)endometrium and it responds to the monthly hormonal cycle similarly to the endometrium which lines the inside of the womb. This ectopic lining also goes through stages of building up and growing, then breaking down and causing bleeding or menstruation(a period). In case of ectopic endometriosis though, the lining that lines other organs causes the menstrual like bleeding to occur elsewhere, for example in the abdominal cavity.(7)
This bleeding may cause inflammation that usually results in formation of adhesions or scar tissue and causes symptoms such as pelvic pain, painful intercourse, heavy menstrual flow, fatigue, painful bowel movements, constipation, and diarrhea.
The most common symptom in women with endometriosis is pelvic pain that is worse just before menstruation. The pain is constant and deep and often radiates to both sides of the pelvis, lower back, abdominal region and buttocks. Some studies showed that polycystic ovaries and hyperandrogenism occur in women taking Valproate for epilepsy.(3)

Some Medications Associated with PCOS
It has been shown that reproductive endocrine disorders are more common among women with epilepsy than among normal women.
Valproate is an anticonvulsant used in the treatment of seizures. The major warning side for patients receiving valproic acid or valproate is that it may cause hepatic failure leading to fatal outcome.
Also valproic acid and some other anticonvulsants may produce teratogenicity or physical abnormalities in the in infants of mothers receiving the drug during pregnancy. (4)
Another medicine that may be associated with PCOS is Clomid.
Clomid (Serophene)- Clomiphene citrate works by suppressing the amount of naturally circulating estrogen so the pituitary gland produces more natural gonadotropic hormones (FSH and LH) that stimulate the ovaries to produce a follicle with an ovum (egg) inside and then release the egg, an event called an ovulation that is ready for feritlization. Women taking clomiphene may produce up to triple the amount of estrogen during that cycle compared to untreated ones.

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Most women do not have any symptoms from taking Clomid. Others may experience some lower abdominal cramps during the last half of the cycle.(8) Rarely in some women the ovaries become over stimulated thus become enlarged and multi cystic and may cause moderate pelvic pain. Additionally large amount of fluid or ascites, may be secreted into the abdominal cavity and consequently lead to heart or kidney failure.

Treatment of PCOS and Endometriosis:
Medical treatment and management in PCOS is directed toward correcting metabolic irregularities, anovulation, hirsutism, and menstrual irregularity. For example, only after 4-12 weeks of dietary restriction and moderate exercising, patients with PCOS exhibited marked improvement in their endocrine and metabolic markers.

Metformin (Glucophage) is an antidiabetic medication that has been shown to improve insulin resistance and decrease hyperinsulinemia and cause an 8-fold increase in ovulation. (9)

Patients with PCOS who are infertile but desire pregnancy should be referred to a reproductive endocrinologist for further evaluation, workups and treatment of infertility.

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Oral Contraceptive Pills and Antiandrogens, such as Spironolactone, are effective for hirsutism in women who don't intend to get pregnant. Caution should be advocated in some cases and preparations that have Norgestrel and Levonorgestrel should be avoided because of their androgenic activity. (7)

In Endometriosis the pain initially is treated with a non-steroidal anti-inflammatory drug (NSAID), such as Ibuprofen (Motrin or Advil) or Naproxen sodium (Aleve).
Then in order to slow the growth of the endometrial tissue outside of the uterus and alter the hormone levels that promote endometriosis, or to lower the estrogen and androgen levels in the body Gonadotropin-Releasing Hormones(GnRH) or GnRH Agonists are used like Synarel, Lupron, Suprefact or Buserelin Acetate, Zoladex. GnRH agonists are stimulators of gonadotropin secretion and because of their action to turn off the ovary in terms of egg maturation they decrease the amount of circulating estrogen and slow down the growth of ectopic endometrium.

Another method that is used by doctors is to try and create a low estrogen and high androgen environment by achieving an anovulatory (no ovulation) state. Initially , this is achieved by using oral contraceptives and with progestational agents like Medroxyprogesterone(Provera), Ethinyl estradiol with progestins (Demulen, Ortho 1/35). Cyproterone acetate is a progestin that has antiandrogen activity and is used to treat hirsutism. This drug has not been approved for use in the United States but it is used in Europe as part of Oral Contraceptive Pills (OCP). Danazol (Danocrine or Cyclomen in Canada), is a drug, synthetic androgen, commonly used to treat endometriosis.

Gestrinone (Dimetriose, Florizel), is a weak progestin with strong anti-progesterone properties that inhibits gonadotrophin release and is also used to treat endometriosis. There are some adverse effects associated with the light androgenic activity of gestrinone but in most cases, the symptoms regress after completing the treatment. (10)

Danazol has been shown to be effective but because of the higher incidence of adverse effects always consult your doctor for risks of taking this medicine.

Lupron
This drug is often used to treat endometriosis in women, prostate cancer in men, early onset of puberty in children or uterine fibroids in women.(11)

Lupron is sometimes prescribed for other uses, you would need to ask your doctor or pharmacist for more information.

Most common side effects with Lupron Depot are generally those related to hypoestrogenism, including vasomotor flushes, headaches and vaginal dryness. A small amount of bone loss may also occur during therapy with Lupron Depot alone, but usually is partially or completely recovered after stopping taking Lupron Depot.(11)

YASMIN is another birth control pill, which contains the same amount of estrogen (ethinyl estradiol) and progestin (drospirenone).
Drospirenone is new class of progestins, and is an analogue of Spironolactone. It has similar anti-mineralocorticoid activity as spironolactone, thus YASMIN affects the sodium and water balance and must not be used in certain women with renal, hepatic, or adrenal conditions that predispose to hyperkalemia(increase serum potassium).

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As for homeopathic medications I have included a couple of reference links for you; this is an area that you may want to research it further.

Some info refers to compounds known as Phytoestrogens.
As the name implies these are naturally occurring plant compounds. There are present in beans, cabbage, soybean, grains and hops, and are part of a wider class of polyphenols found in all plants. Because they are structurally similar to the mammalian oestrogen, oestradiol, and have oestrogenic properties, it has been suggested that they might partly suppress or inhibit normal oestrogenic activity in estrogen-responsive tissues such as breast tissue and may reduce the risk of breast cancer.
More information is available on this site:(13) There are no studies that I know of that have proved that to be true.
The food that is richest by far in phytoestrogens is soybeans. Menopausal supplements made from herbs like black cohosh, red clover, and dong quai may contain soy-like levels of plant estrogens.

Conclusion: When managing PCOS and endometriosis it is best to establish good relationship with the doctor who looks after your needs. Together you could determine appropriate course of treatment for the diseases, address fertility concerns and correction of pain and other symptoms. If surgical treatment is considered then it should be performed by skilled endoscopists who can balance your desired fertility with the need to excise(remove) abnormal endometrial tissue, restore normal anatomy, and treat pain and other symptoms.

In any case, as this is a progressive, ongoing, long term disorder, best is to establish an ongoing relationship with a physician/specialist who can provide appropriate care.


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References and Links

Annals of Internal Medicine of 1 January 1997, volume 126, issue 1, page 32-35 (1)

FERTILITY FEARS(2)

N. England Journal of Medicine, Volume 329:1383-1388,November 4,1993 (3)

The teratogenicity of anticonvulsant drugs(4)

Metformin hydrochloride (5)

Lupron Depot - product information (6)

E-Medicine(7)

Clomid Use and Abuse(8)

Metformin (biguanide)- product information (9)

GnRH Agonists Versus Antagonist, Where Are We Today?

DIMETRIOSE - Datasheet (10)

Lupron- information (11) The Institute of Food Science and Technology (13)

Solvay Pharmaceuticals-product info (14)

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