Image for Painful periods? Acne? Weight Issues?

If any readers have suffered from excruciating period pain, difficult to treat acne, trouble with weight control and fertility issues, or if you, or someone you know has been diagnosed with Poly Cystic Ovarian Syndrome, or endometriosis, then this one is for you.

Polycystic Ovarian Syndrome (PCOS) and Endometriosis are both common gynaecological conditions. Common and major features of each condition is summarised in the table below:

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PCOS affects between 12-21% of Australian women of reproductive age and endometriosis about 10% of women of reproductive age.

Worryingly, 70% of women with PCOs remain undiagnosed and untreated!

(https://www.racgp.org.au/afp/2012/october/polycystic-ovary-syndrome/)

Equally as concerning is the frequency of delaying diagnosis in both conditions. Patients often wait several years to be correctly diagnosed, which leads to unnecessary suffering.

The common occurrence of these 2 conditions should not be used to trivialise them. Sadly this often occurs in clinical practice.

These conditions have a significant effect on many aspects of a patient’s life and can sometimes be relatively debilitating, which is why adequate diagnosis and treatment is so essential to manage the pathology appropriately.

Additionally, given the common occurrence of these conditions the possibility of them occurring together in the same patient is not unlikely. Unfortunately, it is frequent for one, or either condition to be missed; when a woman is diagnosed with the one condition, the other is frequently overlooked, which leads to untreated medical issues and a significant decrease in quality of life.

This is particularly important as both conditions are associated with risks relating to depression and anxiety, which are independently serious medical conditions, requiring specialised treatment.

Patients might have to be their own strong advocates if they suspect some aspects of their health have not been treated.

One of the biggest problems with missed PCOs is that not all women with the disorder present as the classical overweight female with acne and excess body, or facial hair.

The second problem with these conditions lies in their treatment, especially with regards to medications that allow women to skip periods. The gonadotropin releasing hormone analogues, sometimes used in the treatment of endometriosis, can only be prescribed for a period of 6 months due to risks of bone demineralisation and subsequent osteoporosis. This seems a pretty large trade off for a patient, especially when this choice of treatment only offers a temporary 6 months relief from the condition.

There might be safer alternatives for skipping/suppression of menstrual periods. For example, a supplementary dose of cyproterone acetate in addition to the oral contraceptive pill. Of course, all medications have their risks and the choice of medication should be appropriate to an individual patient.

An additional problem with medication for these conditions relates to the use of NSAIDs for management of menstrual pain and inflammation.

NSAIDs are medications that include ibuprofen, naproxen and aspirin. A potential side effect of NSAIDs is heavy menstrual bleeding. Whilst these medications might adequately manage mild to moderate period pain, if very heavy menstrual bleeding results, perhaps they are not the most appropriate analgesia for this particular patient group, especially when heavy periods are a separate, pre-existing
gynaecological complaint.

Finally, as both conditions can include a degree of chronic pelvic pain, inclusion of a chronic pain consultant should be routine in their management, but as these conditions are often not recognised as ‘pain syndromes’ this rarely occurs.

To summarise:

• PCOs can occur together with endometriosis in the same patient

• There is a significant delay (often of several years) in diagnosis of these conditions independently, or comorbidly

• Gonadotropin hormone analogues can cause bone demineralisation

• NSAIDS can increase heavy menstrual bleeding in certain individuals

• A full blood count and possibly iron studies should be ordered in patients presenting with fatigue and heavy bleeding

• In patients with chronic pelvic pain, involvement of a chronic pain specialist should be routine

Useful information and links for endometriosis:

https://www.endometriosisaustralia.org/research

Detailed information about polycystic ovarian syndrome:

https://www.racgp.org.au/afp/2012/october/polycystic-ovary-syndrome/

https://emedicine.medscape.com/article/256806-overview

*Dr Anonymous is known to the Editor