PCOD ( polycystic ovarian disease) is one of the commoner causes of infertility. It’s a chronic disease, which patients need to learn to manage themselves. Sadly, lots of patients with PCOD are very confused. They seem to understand very little about their own problem and I think this is partly because their doctors are very confused themselves and do not take the time and trouble to teach patients about their disease.
Patients with PCOD have irregular periods ; and they know that their irregular periods also means that they will be infertile. How the irregular periods cause infertility is something they are not clear about . They also know that they have a “hormonal imbalance” – but are clueless about which hormones are not in balance.
Because they miss their periods every month, many of them go to the doctor regularly so that he can prescribe medications for them to take in order to induce a period.
While many know that the medicine the doctor prescribes is progesterone, they are very scared to take this for themselves on their own. For one thing, most patients are scared to self-medicate; and they are worried about the side effects of these hormones. Also, their doctors do not empower them with information because they prefer keeping their patients dependent on them ( ensuring them a regular monthly income for these repeat visits).
Below mentioned are the basic principles which every PCOD patient needs to learn :
- You should plan to get 12 periods every year. There’s no point in waiting week after week for the period to come on its own – you are just wasting time and adding to your anxiety levels. Every time you miss your period, you are hopeful that you are pregnant at last – and when the pregnancy test comes back as negative , you get depressed and disheartened again . Why break your heart every month – you need to be proactive ! Getting regular periods is good for your self-esteem and helps you to plan your life. The good news is that there’s no risk or downside to doing so !
- Having irregular periods reduces your fertility ( because you cannot get pregnant until you induce a period). It also messes up the quality your life, because you are never sure when your period is going to start; and it also impairs your health ( a period which comes after many weeks is likely to be very heavy and may lead to your becoming anemic.)
- The good news is that it’s quite easy to learn to self-manage your problem. Why waste time waiting for the period to come when it’s so easy and safe to induce one ? Unfortunately, many patients are scared to self-medicate because of ignorance.
- How do you induce a period ? It’s very simple – all you need to do is to take a 5-day course of a natural hormone called progesterone. This is available in many forms .One of the safest is medroxyprogesterone acetate ( MPA). This can be hard to pronounce; and fortunately, pharmaceutical companies sell this drug under many brand names which are much easier to remember ! These include: Provera; Deviry; and Regesterone. The dose is 10 mg, twice a day, for 5 days. You only need to take 10 tablets- and your period will start about 2-7 days after taking the last tablet. This is called a progesterone withdrawal bleed. By taking this, you are just mimicking nature, which means it’s very safe to do this every month !
- Many women are scared of hormones. They are worried that these hormones will make them fat or cause side effects . Please remember that this is a natural hormone which you are taking only because your own ovaries ( which should normally have produced this every month) are not behaving themselves and producing this important hormone . It’s very similar to managing diabetes. Just like a diabetic needs to take insulin to keep his blood sugar under control ( because his pancreas does not produce the insulin it normally should have) , you need to take the progesterone every month to induce a period. The good news is that it’s not an injection – and you need to take it for only 5 days every month !
- Every time you miss your period, do a pregnancy test to confirm you are not pregnant. Once this is negative, take your course of MPA. Many patients are scared that if they are in fact pregnant, and they then take the medicine by mistake during pregnancy ,this will harm their baby. After all, if the tablet is being used to induce a period, won’t it also induce a miscarriage ? No, this is not true. The good news is that it’s perfectly safe to take MPA during pregnancy as well. In fact, many doctors routinely prescribe this during pregnancy to provide luteal phase hormonal support. Don’t forget that progesterone is a natural hormone which is produced during pregnancy – and as the name suggests, it supports gestation ! If you take it inadvertently during your pregnancy, you will not harm your baby – and in fact if you do not get a withdrawal bleed after taking this course of tablets, one possibility your doctor will need to rule out is a pregnancy. ( The other is a functional ovarian cyst, and a blood test for beta HCG and an ultrasound scan will allow him to make the right diagnosis).
What do I tell my patients ?
I tell my PCOD patients to do a urine pregnancy test on the first of every month ; and when this is negative, to take the course of tablets. This helps them to remember to take the tablets every month !
Some patients get upset at the idea of having to take the tablets every month . They do not like the idea of having to take hormonal tablets every month because they are scared they will get “addicted” to these. Also, they want a cure – a treatment which will fix their problem once and for all !
Sadly, while we are very good at treating the irregular periods you get as a result of your PCOD, we cannot cure it at present. Just like a diabetic’s blood sugar will remain controlled as long as he takes his insulin regularly, your periods will remain regular as long as you take the progesterone. If you stop taking it , the periods will become irregular again. The good news is that it’s possible for you to regularise your cycles – and that this treatment is simple, safe,inexpensive and effective !
If you forget to take your progestins, and get a heavy period, how do you manage this heavy bleeding ? Taking a high dose of antiprostaglandins for 3-4 days ( such as ibuprofen or indomethacin 3-4 times a day) can help to reduce the amount you bleed, and its safe to take these as needed.
Many young girls with irregular cycles with PCOD are told not to worry – and their doctor tells them that their cycles will become regular once they get married.
This is unhelpful advise because it is not true ! The PCOD will need to be treated – and the good news is that safe and effective treatment is easily available – both for regularising the period – and for having a baby !
Remember that while this is effective for regularising your periods, it will not help you to have a baby. This is because all the progesterone does is induce a period – it does not help you to ovulate. If you want a baby, you will also need ovulation induction treatment ! Some patients believe that if they take this “course of tablets ” and regularise their cycle , this will then fix the problem and allow them to get pregnant. This is not true.
In order to get pregnant, patients with PCOD need to take medical treatment. This can be done on a graded basis, starting from ovulation induction; to IUI; to IVF. However, managing these patients can be quite tricky.
It’s important to confirm your husband’s sperm count is normal; and that the tubes are open, before starting treatment for infertility.
For ovulation induction, options include taking metformin, 1500 mg daily; and myoinositol , 2 g daily. While metformin does have side effects and some patients find it dificult to tolerate, it is safe and effective. It’s best to try a therapeutic trial for 3-6 months, before mving on the the next step.
If metformin and myoinositol fail, then you need treatment with clomiphene or letrozole. If this fails, then the next step is IUI.
IUI can be tricky to manage, because of the risk of multiple pregnancies. PCO patients often tend to grow too many follicles when they are superovulated.
The quickest to get pregnant is to do IVF. However, because of the risk of OHSS, this is best done by a specialist, who has a lot of experience in treating PCO patients.
Doctors are often so scared of OHSS, that they end up mistiming the HCG injection, as a result of which they get few eggs and poor quality embryos from patients with PCOD. The irony is that if these patients were superovulated properly, they would grow lots of eggs and have lots ogf high quality embryos !