Polycystic ovarian syndrome (PCOS) is a common but rather complex condition affecting women of reproductive age. It is estimated that up to 21% of women suffer from PCOS, with a significant proportion of them not recognised and not managed appropriately.
Although there is a vast amount of information on the websites and in the literature about PCOS, it is a condition that is not fully understood. The condition was initially believed to be linked to numerous cysts in the ovary, hence the term ‘polycystic ovarian’ with ‘poly’ meaning much or many, and ‘cystic’ meaning relating to or characterized by cysts. It is widely believed that both genetic and environmental factors contribute to its development. However, the actual cause(s) that triggers PCOS remains to be confirmed, which makes determining a diagnosis or implementing an effective cure for PCOS quite a challenge.
Contrary to popular belief, obesity is not a cause of PCOS, but rather an aggravating factor. In other words, women with PCOS may not necessary be obese, but becoming obese could cause symptoms which are associated with PCOS like ovulatory problems and abnormal periods.
The current and most widely accepted diagnosis is based on an international consensus (Rotterdam 2003) which outlines the criteria and characteristics of this condition. Its main objective is to keep the study of PCOS uniform across the world for analysis and comparison of clinical findings and outcome. PCOS is diagnosed if a woman is found to have two of the following three problems:
and when there is no other medical condition attributing to the above findings.
In addition, the diagnosis of PCOS cannot be made if there is other known medical condition (like thyroid disease and congenital adrenal hyperplasia) related to the above findings.
However, this diagnostic approach is not always precise. There is not a single test robust enough to confirm, prove or validate this condition. Moreover, symptoms and clinical findings of PCOS can change from time to time or influenced by other factors like lifestyle-related stress and being on the contraceptive pills. Henceforth, this condition can be easily misdiagnosed and mismanaged, and you may have also received different version or explanation about this condition.
Feeling confused? You’re not alone and that is how many women who have symptoms of PCOS actually feel!
Let’s look at what we know about PCOS – the disease process and its health implications – and what can be done to manage it.
Currently, we know that women who suffer from PCOS are not able to ovulate regularly due to hormonal imbalances. To explain further, it is important to understand basic female reproduction. The brain (or to be precise, the hypothalamus and the pituitary gland) produces hormones (e.g. FSH and LH) which control egg development within the ovary. Out of the many developing eggs (with number ranging from 20 to 100), only one dominant egg is able to reach maturity at any cycle while other developing eggs were discarded in the process. In response to the LH surge, this mature egg is then released, i.e. ovulation, which usually occurs around the middle of a woman’s menstrual cycle.
Each developing egg produces oestradiol (commonly referred to as the ‘female hormone’) and to a lesser amount, androgen. Oestradiol is essential in developing and maintaining female characteristics like breast development, smooth and soft skin, a curvy body shape and thickening of the uterine lining (i.e. endometrium). The more developed the egg is, the more oestradiol it produces. Henceforth, the amount of oestradiol produced can help the brain gauge how well-developed the dominant egg is and the optimal timing for ovulation.
However, for women with PCOS… the egg development is not that straightforward! For reasons not completely understood, the selection of a dominant egg is stalled but the pool of developing eggs keeps increasing in number.
As a result, the ovaries become enlarged and appear polycystic. The growing pool of developing eggs continue to release oestradiol and androgens, which collectively results in some form of hormonal overdrive, causing problems like oily skin, acne outbreaks, excessive hair growth, impaired glucose metabolism and weight gain. This hormonal imbalance also affects the brain’s reproductive regulatory centre, impairing its ability to regulate egg development, maturation and ovulation. The findings of rising LH baseline levels, increased androgen levels and increased insulin levels in PCOS women are indicating some underlying problems in hormonal regulations between the brain, the ovaries and the body.
The presentation and the severity of PCOS can vary markedly from one individual to another because the relationship between altered hormonal levels and the associated clinical features is not always consistent, and this can make the diagnosis of PCOS challenging. It is therefore imperative that a proper assessment comprising of history taking, blood tests and ultrasound scan is undertaken to determine the diagnosis of PCOS and its severity. It is important to seek professional advice, not only to receive appropriate, evidence-based treatments for immediate and long-term management, but also to gain a better understanding of PCOS and dispel the many myths surrounding it.
Although there is no curative treatment for PCOS, the condition tends to improve gradually with increasing age, especially after adolescence. Moreover, the condition can be well managed with appropriate treatment which can involve a combination of the following:
A low calorie diet alongside plenty of aerobic exercise to achieve and maintain a healthy weight;
Hormonal therapy such as the combined oral contraceptive pills, preferably those with anti-androgen effects to regulate menstrual cycles and to correct hormonal imbalance and its associated problems. Alternatives to the pills are depot Provera, Implanon and Mirena IUD;
Specialist treatment for acne, excessive hair growth, glucose intolerance, fertility issues etc.
Contrary to popular belief, women with PCOS can conceive naturally but may need some form of fertility treatment which is not necessary an IVF treatment.
As PCOS and its clinical impact vary from woman to woman, management of this condition should be individually tailored and progress should be monitored long-term by a dedicated doctor.
Having a baby is one of our greatest milestones in life – it is a wonderful experience to be able to give birth to our children and raise a family. There are many books and reading materials out there on pregnancy, but our specialist will help you focus on what is important and relevant to you.
Here, we take a holistic approach to understand your needs, to demystify myths surrounding fertility, pregnancy and childbirth, and to manage problems which can affect your chances of having a healthy baby. Getting a pre-pregnancy counselling allows you to address all your concerns with our specialist who will listen to your queries, systematically assess your health and give you a comprehensive yet easy-to-follow roadmap. This process will start with a comprehensive history taking, an appropriate examination, and a set of blood tests and ultrasound scan. You will then receive counselling about your health status and ways you can do to enhance your health and your chances of having a spontaneous pregnancy. This would give you better preparation and greater confidence in going to the next stage of your journey to having a baby.
One pertinent point to note, don’t wait too long to start a family – get a fertility check-up which includes an assessment of your ovarian reserve to help you work out how much time left in your reproductive lifespan before it is too late. We can discuss the option of storing your valuable eggs or embryos if you wish to delay your childbearing plan.
Further reading on Pregnancy Planning
Having a baby is a very personal journey. Some find it easy and straight-forward, others have a tougher and more risky journey. Whichever journey you go through, it is a personal one, which makes it sweeter if you have someone supporting you through, and have a specialist guiding you all the way to experience the best moment of your life – the birth of your precious baby. You may have read or hear stories about the things that could go wrong in pregnancy and childbirth, and may be constantly worrying about labour pain and how on earth the baby can come out.
Yeap, those worries are legitimate because pregnancy and childbirth can be risky and potentially life-threatening to mother and/or baby, and these complications can happen even in young, healthy and supposedly low risk pregnant women. Looking back at history, it was not too long ago that our grandparents and the generations before them dreaded about the moment of not seeing their wife and baby survive through the childbirth process, and now these events are very uncommon, thanks to modern surveillance of pregnancy progress and childbirth in the labour ward with modern facilities like operating theatre, blood-bank, and nursery to provide emergency backup in case of any unexpected complications.
Our mission is to ensure you have a memorable pregnancy and childbirth experience; to support and guide you and your partner throughout this very personal journey; and above all, to make this process safe and comfortable.
In our clinic, you will see the same specialist throughout your pregnancy care, who is almost certain will be there delivering your baby. Your pregnancy care will include a comprehensive assessment and a personalised pregnancy care plan. With each subsequent antenatal visit, our specialist will monitor your health; the growth and well-being of your baby with an ultrasound scan to check your baby’s position, heartbeat, growth and fluid in the womb; and address any concerns along the way. You will be encouraged to attend antenatal classes organised by the private hospital you intend to have your confinement. The choice of delivery and pain management will be discussed to select the one you prefer, and although we would normally promote natural birth, how you wish to have a baby is entirely your choosing as long as it is deemed safe and reasonable. This would mean no homebirth or water-birth, and we would reason out with you why those choices pose a potential risk to you and the people looking after you.
We also put a strong focus on good pain management as we understand that labour can be painful and women can have varying degree of pain tolerance. Good pain management ensures you have control over your birthing experience, and help you avoid traumatic childbirth.
Our overriding goal is to provide you and your partner a comprehensive first-class professional care throughout your pregnancy journey til you have your baby in your arms, and to not only ensure a safe outcome but also bring you a memorable and wonderful experience. We call this, having your baby in extraordinary style.
The following is an example of a pregnancy care schedule.
Family planning is basically a strategy to influence the number of children one wishes to have and when. Although it is often not a precise method, it allows people to choose and to manage their family size and structure, and this is often a very personal choice influenced by one’s background, faith and society. There are many different methods to choose from and basically can be categorised into 5 groups: natural methods, barrier methods, contraceptive pills, non-pill alternatives, and sterilisation.
There is no right decision, just one which suits your needs and is compatible with your belief and values. It is also something that can change over time, and as such, it is important to choose methods which give you the flexibility to change your plan as your circumstances evolve.
Reaching menopause can be a life changing event for women as it indicates the end of reproductive age. The experience of going through menopause is highly individualised, from minimal symptoms to significant disruption to one’s daily living. It can be influenced by various bio-psycho-social factors like health condition, lifestyle, family history and cultural factors etc. Click Read More to find out more about menopause and its management.
What is menopause?
Menopause is a natural aging process that usually begins at 45-55 years of age, with an average age of onset in Australia at 51 years. Sometimes, it can be brought on by medical or surgical treatments. As we know, the ovary produces female hormones (oestrogen and progesterone) in a cyclical fashion to stimulate breast development and to regulate menstrual cycles through the growth and subsequent shedding of the womb lining (also called the endometrium). These hormones are actually produced by the maturing eggs, and hence, as the egg reserve becomes depleted with aging, so also the ovarian hormone production which starts to become erratic and eventually the levels become negligible. This explains why women approaching menopause often experience irregular periods which can also be heavy. This duration, which is also known as perimenopause or the transitional phase, can last for several years which can be a rather disturbing time of one’s life. Medically, a woman is diagnosed to be in menopause after she has gone for one full year without periods. From then onwards, the woman is considered to be in the postmenopause.
What are the symptoms?
Typical symptoms are irregular period, hot flushes and night sweats. Other common symptoms are headaches, mood swings, sleeping difficulty, general aches and pains, and tiredness.
In the long run, there are some recognised associated changes affecting other parts of the woman’s body like dry skin and hair, dry vagina, breast changes, increased urinary frequency, weak bladder and accelerated bone calcium loss resulting in osteoporosis.
How is menopause diagnosed?
Menopause can be diagnosed when your period has stopped for a continuous 12 months and you are over the age of 45. If you are taking specialised medications to suppress your FSH production, your menopause can be medically induced until such time you come off the effect of the medications. And if you have both ovaries are removed surgically, your menopause will occur soon after.
For women reaching menopause before the age of 45, your doctor can organise a simple blood test (for FSH and oestradiol levels) to help confirm the diagnosis, and consider further tests to screen out other medical conditions like hypothyroidism, anaemia or depression which can mimic, or sometimes co-exist with, menopause.
How is menopause managed?
It is important to accept that menopause is a natural course of life and nothing to be embarrassed or worried about. Although nothing can be done to prevent menopause, unpleasant symptoms can often be reduced by maintaining a healthy lifestyle with a well-balanced diet and regular exercise; and having supportive friends and positive thinking. Some general tips you may wish to try are:
Talk to your doctor about the option of going on hormone replacement (HRT) so that you can consider the benefits and purported risks associated with HRT. Studies have demonstrated that HRT is by far the most effective therapy for controlling menopause-related problems. Most importantly, management should be individualised as each woman's experience is different and unique. A proper counselling in this regard is very worthwhile.
What to prepare before going to your appointment?
Because there are a lot of things to discuss during consultation, it is a good idea to do some preparation before you go and see your doctor.
For further reading:
Vaginal prolapse is very common in women, believed to be over 30% of the female population. Conservative treatment includes pelvic floor exercises, pessary support and vaginal oestrogen supplement (for postmenopausal women).
Surgical options can be divided into 2 main groups: 1) reconstructive, and 2) obliterative types. The former option is suitable for women who wish to retain vaginal sexual function.
For reconstructive surgery to be durable in preventing recurrent vaginal prolapse, the supportive fascia would have to be strengthened and reinforced, and this can be achieved by a combination of physiotherapy, oestrogen supplement, and native tissue repair using dissolvable sutures. Unfortunately, this approach still accounts for a recurrent rate of 10% to 70%.
To improve on our long term clinical outcome, several approaches have been introduced. Mesh was popularised in the 2000s and not long after, had been introduced worldwide as the panacea for vaginal prolapse.
In recent years, there have been quite a lot of bad publicity against the use of artificial meshes as more and more women reported unacceptable complications like dyspareunia and mesh erosion. Mesh erosion rate was reported as high as 25%.
Cochrane review recently reported a significantly higher rate of needing repeat surgery in women who had transvaginal mesh surgery compared to those who had native tissue repairs.
These complications resulted in some high profile lawsuit in the United States and review by the FDA.
Facing the threat of expensive lawsuits, many manufacturers of mesh began to withdraw their products from the market, e.g. Ethicon, AMS and Bard. AMS which became Astora in 2015 decided to settle more than 20,000 of its own cases for reportedly more than $2.4 billion.
Now, the only manufacturers left to provide transvaginal mesh in Australia is Boston Scientific and Restorelle. Studies on their mesh products are too limited to draw a conclusion on benefits & safety.
Our View & Approach:
We have always been sceptical of the use of transvaginal mesh because of the unique anatomy & function of vagina as opposed to abdominal hernias. So far, all our patients who needed vaginal prolapse repair did not end up having mesh put in.
Our approach to women needing prolapse repair is to have:
1) Good patient selection
2) Proper preoperative preparation
3) Careful anatomical repair
4) Long-term postoperative care
With patient selection, we offer vaginal reconstructive surgery in those whom we think have reasonable healthy native tissue. Those who have very weak tissue / fascia and are not sexually active are given the option for obliterative surgery, also called colpocleisis, which have a very low rate for recurrence and complications.
For those who wanted vaginal reconstructive surgery, every effort is made to strengthen their native tissue and maintain this long term. Our recurrence rate is comparatively low, with only two known cases in the last 5 years! As expected, there have been no reported failure rate for vaginal obliterative surgery in our cohort of patients.
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Phone: 08 8297 4338
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