PCOS

he hairy sex Your Health Dr Gita Mathai Poly cystic ovarian syndrome is genetic. Many close female relatives may also be obese and hirsute, with menstrual problems and infertility Obese girls could develop PCOS (above) and exercise might help Girls change physically when they attain puberty, and most mature into attractive women. A few become unrecognisable. They become obese, develop acne and have hairy arms and legs. They sprout facial hair, develop a receding forehead and, if there is a familial tendency, male pattern baldness as well. This in itself is enough to make parents anxious. If, in addition, the periods are also irregular, scanty or excessive, parents often bring the girl for evaluation. Most of these women have poly cystic ovarian syndrome (PCOS). This affects 10 per cent of the women in the childbearing assge group. In addition to the typical physical characteristics, an ultrasound shows multiple fluid filled cysts dotting the periphery of both ovaries. The changes are due to a relative insulin resistance. These women show blood values of high fasting insulin levels of over 10 IU/mL (international units per millilitre), although 25-30 IU /mL is the cut off in men and older people. The ovary responds to this high insulin level by producing more male hormones like testosterone. The brain responds by resetting the pituitary ovarian control axis and its chemical messengers. The eggs in the ovaries remain immature fluid filled sacs and are not released (anovulation). Anovulation, unbalanced hormones, irregular feedback from the brain, all these reasons cause irregular menstrual cycles, relative infertility and, later, recurrent pregnancy loss. PCOS is genetic and probing questions will reveal relatives (male and female) with adult-onset diabetes, obesity, high values of triglycerides and high blood pressure. Many close female relatives may also be obese and hirsute, with menstrual problems and infertility. Unfortunately, although many of these patients seek help during their late teenage years, they are not investigated or diagnosed properly. They are offered placatory advice instead and given iron and calcium supplements. Some are given mysterious proprietary aryuvedic “gyno mix” tonics. Others are assured that the condition will spontaneously resolve itself after marriage. Nothing could be further from the truth. Treatment and lifestyle changes have to be made to correct the cascading biochemical abnormalities. Weight control is the mainstay of treatment. As far as possible, only 1500 — 2000 calories should be consumed a day (20 kcals/kg/day). Carbohydrates should be complex so that digestion and assimilation take time, increasing satiety. At least four helpings of fruits and vegetables should be eaten every day. Dieting alone causes initial weight loss after which there is a plateau and then the weight starts to increase again. To sustain and maintain the correct weight, diet has to be combined with aerobic exercises like walking briskly, jogging or cycling for 45 minutes a day. Medications like metformin,rosiglitazone and pioglitazone either singly or in combination correct the biochemical abnormalities. This is itself may regularise the cycles and restore regular ovulation. Oral contraceptive pills (OCPs) provide oestrogen and progesterone in the correct proportions to artificially produce regular menstruation. The hirsutism and acne also decrease as the pills restore the hormonal balance. However, if the woman wishes to become pregnant, OCPs should be discontinued. Other medication like clomipheneor letrozole should be taken on the appropriate days under strict medical supervision. Surgical treatment can be performed by expert and experienced doctors. Traditionally a “wedge resection” of the ovary was done and then ovulation was induced with medications. Now there are newer techniques. Each ovary can be drilled and punctured 10 -12 times through a laparoscopic puncture wound using a laser fibre or electrosurgical needle. This results in a dramatic lowering of male hormone levels in 80 per cent of cases within days. Many women who did not ovulate initially with letrozole or metformin therapy will do so after ovarian drilling. Interestingly, women who smoke, take snuff or chew tobacco rarely respond to the drilling procedure. Once women with PCOS become pregnant, only half the battle is over. They are more prone to developing gestational diabetes, hypertension in pregnancy and have a poor outcome with abortion or still birth. If they have become pregnant after taking fertility medication, they are more likely to have multiple pregnancies, with twins or triplets. As women with PCOS grow older, their menstrual cycles may become normal. They still remain at risk for diabetes and hyperlipidemia. Both these increase the risk for strokes and heart attacks. They are also at higher risk for uterine cancer. If you have PCOS, remember it can be controlled but not cured. Reduce your risk factors with diet and regular exercise. Keep your weight in the normal range and go for regular annual check ups to detect and reduce your risk factors. Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.in

painful nerves

ouch a nerve Your Health DR GITA MATHAI One out of every two people in India suffers from neuropathy — a disease caused by changes in the nerve cells. These changes may be age related. The degeneration is accelerated and aggravated if the patient suffers from diabetes, hypertension or has an abnormal lipid profile. Neuropathy can affect all three nervous systems — central, peripheral and autonomous. If the central nervous system is affected, memory and cognitive skills decline. Forgetfulness becomes an accepted way of life. Peripheral neuropathy produces the most obvious, incapacitating, and distressing symptoms. In some, the affected nerves may produce symptoms that are symmetrical (occurring in both limbs) and appear first in the furthest extremity. There may be paraesthesia (tingling, burning or numb sensation), hyperalgesia (abnormally acute pain sensation to innocuous stimuli) or deep aching. The symptoms tend to get worse at night and interfere with sleep. In others, the sensation of and response to pain may be lost. Injuries can occur unnoticed. Infection may set in and be neglected because there is no warning pain. Healing may be delayed as unnoticed micro trauma continues to occur. Ulcers become chronic. The nerves supplying the muscles can also be affected, leading to weakness and atrophy. Muscles visibly shrink, resulting in hammer toes (toes curve downwards) or drop foot (moving toes and ankle become difficult). Weak muscles cannot hold the joints in place efficiently, leading to sprains and fractures. The symptoms of autonomic neuropathy are not as clear-cut. Patients complain about unrelated symptoms such as dizziness, poor balance and frequent falls, fainting spells, nausea, abdominal pain and bloating, attacks of “gas” or sexual (especially erectile) dysfunction. These symptoms are difficult to objectively evaluate or substantiate. The condition is ignored and under-diagnosed. Such patients can die suddenly because of malfunction of the autonomic nerves supplying the heart. Neuropathy is more likely in people with the metabolic syndrome. This is diagnosed when there is increased level of fasting glucose, elevated triglycerides, decreased high-density lipoprotein-C (HDL-C), central obesity, and hypertension. At least three of the five should be present. Thirty per cent of the people affected by peripheral neuropathy are diabetics. Of these, 20 per cent are unaware of their elevated blood sugar level, which is diagnosed during the blood tests done for the evaluation of neuropathy. Smoking or the use of tobacco in any form is an independent risk factor. The cancer-causing chemicals in tobacco enter the blood stream and affect the brain and the lining of the nerves. Alcohol acts as a direct poison on the nerves. It also interferes with the absorption of the B group of vitamins. A neuropathy results, which does not respond to treatment until alcohol consumption is stopped. Diseases of the intestines that cause malabsorption can lead to vitamin deficiency and from there to neuropathy. Surgery to remove portions of the intestine can have the same effect. Keeping blood sugar, weight, hypertension under control and regularising lipid profile reduce the symptoms of peripheral neuropathy. The damage to the nerves is reversible in the early stages. Once neuropathy is established, however, response to treatment is unsatisfactory. Many adjuvant medications have been tried, such as mega doses of vitamins, iron, zinc, calcium, alpha lipoic acid, acetyl-L carnitine. Increasing doses of painkillers like tramadol are also used. Sometimes they are combined with anti histamines like diphendydramnine (Benadryl) and pain modifying drugs. Combinations with anti epileptics such as gabapentin and anti depressants like amitriptyline reduce the intensity of symptoms. None of these treatments has been 100 per cent successful. The pain is still present in 80 per cent of the patients 5-10 years later. The intensity of the pain can be reduced by soaking the legs up to the knees in warm salted water for 10 minutes, half-an-hour before bed. Application of pain relieving ointments that contain capsaicin also provides relief. The ointment should be applied every 3-4 hours. Do not rub the ointment in too vigorously as it will damage the skin. Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.in

mental illness in children

roubled minds Your Health DR GITA MATHAI The image we have of a mentally-ill person is that he or she runs around unkempt, if not naked, and speaks gibberish. That is not necessarily correct. Mental disorder covers a spectrum of symptoms, from the deranged person unable to care for himself or herself to the unreasonable, paranoid or socially offensive member of society. Most mental illnesses start in childhood. Around 20 per cent of children and adolescents (2-18 years) suffer from psychiatric disorders, which initially manifest with minor symptoms. Parents and caregivers ignore early symptoms, confident that the child will “grow out of it”. Even when symptoms are severe, obvious and socially embarrassing, parents are chary about seeing a psychiatrist because of the perceived social stigma attached to it. Undiagnosed and untreated, the illness becomes a full-blown disease by the time the patient becomes an adult. In children, the symptoms are often vague and difficult to classify as “abnormal”. Shyness, anxiety, speech peculiarities and temper tantrums may appear normal. Also in nuclear families, parents and grandparents may adjust to behaviour that is not normal. Any consistently inappropriate behaviour that occurs often, lasts a long time and repeatedly disrupts the child’s life or family should be taken seriously and investigated. The symptoms that should be taken seriously are hyperactivity with an inability to sit down and concentrate on any task, refusal to eat, difficulties in urination or passing motion, poor school performance, difficulty in sleeping, defying authority, refusing to attend school, outbursts of temper, disobedience, stealing, damaging property, poor social skills with no friends and having nightmares. The illness is already severe if the child hallucinates. Children who suffer from psychiatric problems like anxiety are socially withdrawn and nervous. They may avoid places or activities. ADHD (Attention Deficit Hyperactivity Disorder) affects 3-5 per cent of school children. It is commoner in boys. The symptoms are inattentiveness, overactivity, and impulsive or inattentive disruptive behaviour with or without learning disability. Autistic children withdraw into themselves, lack empathy, dislike or avoid physical contact and have poor language and communication skills. They cannot make friends. Meal times may become stressful because they refuse to eat. There may be extreme mood swings. The exact cause of mental illness is not known. It is probably the result of a combination of factors in a susceptible individual. It does tend to run in families, especially if many members have major or minor psychiatric illnesses. This may also be because a mentally ill parent cannot nurture a child appropriately. It does not, however, mean that children of parents with mental disorders will necessarily develop the disease. Chemicals called neurotransmitters convey signals from one brain cell to another and thereby control all brain activity. If the chemicals are not in proper proportion or sync, the imbalance can lead to symptoms of mental disorder. The imbalance may be hereditary or the result of an injury or illness. Stress in any form, either psychological (loss of a parent) or environmental (war or violence) can also affect the levels of these chemicals and precipitate mental illness. Children with psychiatric problems do not grow up and grow out of their illness. They require appropriate and timely treatment. Although more than 50 per cent of mental illnesses begin by the age of 14, it often stays undiagnosed. If the illness becomes worse, the child may be forced to drop out of school. He or she may have suicidal tendencies, may attempt suicide and actually succeed. The child may become dependent on drugs or alcohol and become sexually promiscuous. Adults can visit a doctor. Children, on the other hand, need to be taken to a doctor after parents recognise the symptoms. They need to be evaluated by a paediatrician and a child psychiatrist. Once a diagnosis has been made, a combination of behavioural therapy, psychotherapy and occupational therapy is used. Medication is required in certain children, but it needs to be used only as a last resort. Major psychiatric problems such as schizophrenia require appropriate medication. Children need a stable home environment to develop normally. They need adequate discipline. Winning your child’s affection by undermining the authority of the other parent or being overly indulgent is detrimental. It sends mixed signals to the child and leads to emotional conflict. Exercise is very important for mental and physical development. Structured outdoor activity for at least half an hour daily is required after the age of three. This helps to regulate neurotransmitters. Television viewing needs to be supervised as well as curtailed. The rapidly flashing images deplete neurotransmitter levels. Children should not watch programmes unsuitable for them as well as violent cartoons. Parents, spend an adequate amount of time with your child. This way you will immediately pick up on any problems. Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.in Share on emailShare on printShare on facebookShare on twitterMore Sharing Services