Polycystic ovary syndrome history, modern and unani approach ppt.pptx

Poly cystic ovarian syndrome pptx.
Including history of pcos
Relation to diet
decrease in metabolism
Central obesity
recent diagnostic criterias
Unani concept
single and compound drugs
modern medicine treatment and unani medicine treatment
ACOG guidelines and description given by ancient scholars
Action of drugs used by gynec in their OPDS

1. Polycystic ovarian syndrome FAIZA FURQAN JR2 DEPTT. NISWAN WA QABALAT

2. contents Introduction Incidence Pathophysiology Pathology Clinical features Investigation Management Unani aspect and management

3. Introduction Polycystic ovarian syndrome (PCOS) is the most common endocrine pathology in females of reproductive age worldwide. Irving Freiler Stein and Michael Leventhal initially described it in 1935. The prevalence ranges between 5% and 15% depending on the diagnostic criteria applied. It is widely accepted among specialty society guidelines that the diagnosis of PCOS must be based on the presence of at least two of the following three criteria: chronic anovulation, hyperandrogenism (clinical or biological), and polycystic ovaries. Multiple morbidities are associated with PCOS, including infertility, metabolic syndrome, obesity, impaired glucose tolerance, type 2 diabetes mellitus (DM-2), cardiovascular risk, depression, obstructive sleep apnea (OSA), and endometrial cancer .  

4. Etiology The exact etiology is not known yet but…… Several susceptible genes have been identified as contributors to the pathophysiology of the disease. These genes are involved in various levels of steroidogenesis and androgenic pathways. Twin studies have estimated about 70% heritability and a lso the environment is a fundamental component in the expression of these genes in the development and progression of the disease. The most common environmental factors include obesity and insulin resistance . ( Goyal A, Ganie MA. Idiopathic Hyperprolactinemia Presenting as Polycystic Ovary Syndrome in Identical Twin Sisters: A Case Report and Literature Review.  Cureus . 2018 Jul 19;10(7):e3004.)

5. Pathophysiology Chronic anovulation : Steady state LH/FSH, No progesterone- Irregular bleeding Increased androgens: LH stimulation of theca cells & decreased SHBG from liver. Free testosterone rises (Hirsutism) Enlarged ovaries: Multiple peripheral cystic follicles fail to mature an apoptosis ceases due to increased androgens. Premature follicle atresia despite of follicle stimulation from steady state FSH Causes for Increased Androgen Level

6. Causes for increase Androgen level Increased frequency of GnRH pulses, so LH rises Insulin stimulates theca cells with LH to produce androgens Insulin also synergistically act with androgens to decrease hepatic production of SHBG, thus increasing free or active testosterone

7. PATHOLOGY Ovaries are usually 2–5 times the normal size, gray white with a smooth outer cortex, and studded with subcortical cysts. Multiple cysts (12 or more) of 2-9 mm size are located peripherally along the surface of the ovary Ovary which amounts to more than 10 cm3 in volume Enlarged ovaries contains : Excessive follicles Theca cells and Stromal hyperplasia Thickened capsule

8. CLINICAL FEATURES Young woman; Central obesity (BMI>30 Kg/m 3 ) Oligomenorrhoea (87%), amenorrhoea (26%) followed by prolonged or heavy periods. Infertility (20%) Pregnancy loss (20–30%) Hyperandrogenism : Hirsutism, Acne, Acanthosis nigricans

9. HAIR AN SYNDROME

10. Modified Rotterdam Criteria Any Of The Two Required Feature Recommended Diagnosis Considerations Biochemical Hyperandrogenism Elevated total or free testosterone, or calculated indices of free testosterone. DHEAS and ANSD can be consider High-quality assays should be used for the evaluation of analytes Clinical Hyperandrogenism A modified Ferriman –Gallwey score of ≥4 to ≥8(gold standard in evaluation of hirsutism). Threshold level should be considered in the context of patient ethnicity

11. Oligo-anovulation Oligo-amenorrhea (cycles >35 days apart or <8 menses a year) If highly suspicious for PCOS, but does not have oligo-amenorrhea, consider serum progesterone or luteinizing hormone assessment Polycystic ovarian morphology ≥20 follicles per ovary in either ovary ≥10 cm 3  ovarian volume Based on transvaginal ultrasonography with a transducer frequency ≥ 8 MHz Criteria based on the modified 2003 Rotterdam criteria. FAI—free androgen index, BioT —bioavailable testosterone, DHEAS—dehydroepiandrosterone sulfate, ANSD—androstenedione. (Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA 94143, USA)

12. Investigation in case of PCOS Sonography Reassessment of BMI, BP, waist circumference Serum levels of FSH, LH, TSH, Prolactin, DHEAS 2 hrs oral glucose tolerance test Lipid profile

13. Investigation Sonography(TVS 8 mHz – in case of obese). Serum values Oestrone and estradiol level rises LH level is raised over 10 IU/mL FSH level remains normal, LH:FSH level >3:1 SHBG level falls due to hyperandrogenism Testosterone and dyhydroepiandrosterone levels rises. Thyroid function tests may be abnormal (hypothyroidism) Cytochrome P450c17:a multifunctional enzyme that converts C21 steroids to the C19 sex steroid precursor DHEA might be increased

14. Goal of management To cure a women with menstrual disorder To treat hirsutism To treat infertility

15. Non pharmacological Therapy Weight loss: – Weight loss of more than 5% of previous weight alone is beneficial in mild hirsutism – It restores the hormonal milieu – It increases secretion of sex hormone binding globulin from liver thereby reducing testosterone level. – Reduces insulin level Lifestyle: – smoking cessation (lowers E2 levels and raises DHEA and androgen levels

16. Pharmacological For hyperandrogenemia COCs- progestin suppresses the LH and estrogen which improves SHBG, reducing free testosterone Hirsutism-cyproterone acetate, spironolactone, flutamide.(D.C Dutta) 4th generation combined pills (containing 30 μ g E2 and 2-3 mg drospirenone (A progestogen with antiandrogenic action) – Reduces acne and further hirsutism – Prevents water retension and reduces weight. – Maintain lipid profile Progestogen- to induce menstruation in amenorrhoeic woman prior to initiating hormonal cyclical therap y. OC with cyproterone - if the woman has hirsutism.

17. OVULATION INDUCTION DRUGS Oral drugs Letrozole 2.5-5mg (1 st line drug to induce ovulation) Clomiphene citrate 50-200mg Tamoxifene Metformin (for obese women, it make circulating insulin more sensitive ) Injectables Gonadotropins ( they are the agents which act on gonads and have tropic effect on gonads releases from pituitary)FSH and LH Urinary( from urine of post menopausal women) Recombinant(FSH,LH)

18. C lomiphene citrate – inhibits the estrogenic receptors in the hypothalamus Inc. FSH and leads to bigger follice and mature follicle will rupture Ovulation will happen From 2 nd to the 6 day of menstrual cycle…….. Follicle start inc. Ovulation can happen to 80% Preg . Can occur 40% Letr0zole (aromatase inhibitor ) Androstenedione esradiol Latrozole inhibits the formation estradiol net amount of estrogen will reduce, FSH inc from 2 to 6 day of menstrual cycle

19. Metformin To treat root cause, rectifies endocrine and metabolic functions, improves fertility rate, is used as insulin sensitizer Class of drug: Biguanide Inhibition of hepatic glucose production – Decrease intestinal glucose absorption, increase peripheral insulin sensitivity Also reduces the level of total and free testosterone and increases the sex hormone binding globulin

20. Surgery Reserved for – Medical therapy fails – Hyperstimulation occurs – Infertile women – Previous pregnancy losses – Surgery comprises laparoscopic drilling or puncture of not more than four cysts in each ovary either by laser or by unipolar electrocautery – Restores endocrine milieu, improves fertility for a year or so. – Pelvic adhesions caused by surgery may again reduce fertility rate

21. UNANI ASPECT OF PCOD In the  unani  traditional medicine system all diseases are considered to arise due to imbalance in the quantity and quality of the four humors i.e   akhlāṭ arba ‘a ( dam ,  ṣafrā ,  sawdā  and  balgham ). PCOS is not described as such in the classical  unani  texts. However, it can be correlated with the symptoms such as  iḥtibās -al- ṭamth  (amenorrhea),  uqr  (infertility) and obesity.

22. Su’- i - mizaj barid  (alteration in the temperament) of the liver lead to abnormal production of balgham (phlegm) abnormal forms of  balgham   is  balgham ma’i , which is much diluted in consistency and possesses a tendency to accumulate in a sac to form cysts.  giving rise to various symptoms such as  iḥtibāsal-ṭamth ,  uqr  and obesity 

23. According to Razi, constellation of signs like hirsutism, obesity, acne, hoarseness of voice and infertility conjoined with menstrual abnormalities like amenorrhea, oligomenorrhea are suggestive of PCOS. Razi , says that ‘ Ihtibas al- Tamth ’ occur in fair women with phlegmatic temperament ( Razi ABZ (2001) Al Hawi Fil Tibb . Vol IX, CCRUM, India pp. 151-168 ) Hippocrates stated that a woman having scanty flow during periods or duration of flow <3 days may have robust body, healthy complexion with masculine appearance and infertility ( Khan AA, Begum W, Mustafa S (2018) polycystic ovarian syndrome from Greeko -Arab to the Present: A Review. WJPMR 4(4): 68-72.)

24. Usool -e- Ilaj (Principles of treatment) Idrar - e- haiz with use of mudir-e- haiz drugs. Tadeel mizaj with use of munzij wa mushil balgham drugs. W eight reduction. (Razi ABZ. 2001. Al Hawi Fil Tib. Vol IX. CCRUM. New Delhi. 77-86, 90-91, 99-100, 102-03, 106-08, 110-11, 115-16)

25. Tadeel Mizaj (Correction of temperament): a) Munzij : Mavez Munaqqa , Badiyan , Aslusoos , Persia wa Shan, Anjeer Zard b) Mushil : Ayarij Faiqrah , Turbud , Habun Neel with Arqe Badiyan . c) Tabreed : Khameera Gauzaban Sada wrapped in Warq e Nuqra Weight Reduction : a) Dawae Luk Sagheer with Arqe Badiyan b) Safoofe Muhazzil with Arqe Zeera. c) Itrefil Sagheer at bed time. Specific Drugs: a) Use of insulin sensitizers like Darchini , Rewand chini , Abhal , Mushktramashi , Zafran , Asgand etc. b) Natural drugs for hirsutism like Nagarmotha , Amba Haldi , Methi , Pudina, Soy a, Neem, Kalonji etc. Khan A. Al Akseer (Urdu translation by Kabeeruddin ). New Delhi: Idarae Kitabus Shifa ; January: 2011; 797-801. Firdose KF, Begum W, Shameem I. Clinical Evalution of Qillat Tams and its Management with Unani Formulation. International Research Journal of Medical Sciences. 2013; 1(11):1-8.

26. Single Drugs : Abhal , Badiyan , Post Amaltas ,, Persiawa Shan, Asgand , Aspand , Habbe Balsan , Habbe Qillt , Habbe Qurtum , Rewand Chini , Tukhme Kasoos , Khashkhash , Gule Teesu , Karafs , Elwa , Heeng , Jausheeer , Asaroon , Turmus , Tukhme Gazar. Compound formulations: Habbe mudir, Joshanda mudir haiz , Sharbat buzoori , Murakkabate foulad Itrifal Gudoodi , Majoon Dabidulward These emmenagogue drugs are used with uterine tonics like majoon muqawwi rehm which consists of asgand only as it contains phytohormones which induces the menstruation by maintaining hormonal balance

27. Recent diagnostic parameters Antimullerian hormone [AMH] levels proposed as a parameter to replace ultra-sonographic assessment. Another diagnostic parameter is an assessment of ovarian stromal volume, measured as a ratio of stromal area to the total area of the ovary (S/A ratio) (Ruta K. Contemporary and traditional perspectives of polycystic ovarian syndrome (PCOS). J Dental Med Sci 2014;13:89-98)