An insight into adolescent polycystic ovarian syndrome and its management with homoeopathy – A case report

INTRODUCTION

Classical polycystic ovarian syndrome (PCOS) is also known as Stein–Leventhal Syndrome.^[1] The classic features of PCOS include chronic anovulation associated with relative infertility, polycystic ovarian morphology, and hirsutism. The adolescent onset PCOS is a relatively newer diagnosis with confusion in the diagnostic criteria as there may be overlapping in normal pubertal development and characteristic features of PCOS.^[2] As of now, there are no definitive parameters for diagnosis and treatment of adolescent PCOS. The prevalence in the adolescent age group was studied and came around 11.04%^[3]. As per the study conducted in Southern India found the incidence to be 6.8% whereas a systematic review gave a prevalence of 17.74%.^[4,5] Lifestyle changes^[6] form a solid ground for recovery from PCOS, which includes weight loss and physical exercise. It is associated with significant lowering of testosterone levels and an increase in sex hormone-binding globulin (SHBG) and helps in regulating menstrual irregularities with absolutely no side effects as compared to conventional medications. It also causes significant risk reduction in cardiovascular diseases such as hypertension, dyslipidaemia and glucose intolerance. Treatment modalities in the conventional line of treatment include combined oral contraceptive pills as the first line of treatment in adolescents. The oestrogen part influences increasing SHBG and reducing luteinising hormone, which leads to a reduction of the free androgen index. The progestin component allows for the suppression of endometrial proliferation and regular withdrawal bleeding. It also has an effect in reducing acne and hirsutism.^[6] Cyproterone acetate, an efficient and potent progestin with antiandrogenic activity, is one of the other therapy options. However, using this progestin carries a risk of hepatotoxicity and meningioma.^[7]

Adolescents who suffer from PCOS are seen to have a lower quality of life when compared with healthy adolescents.^[8] Along with compromised metabolic and reproductive aspects, individuals are at a greater risk for depression and stress. The main factor cited as contributing to adolescent depression and mental stress is obesity.^[9]

Homoeopathy has been useful in the treatment of diseases of mankind for a long time. There is very little evidence available with respect to the treatment of cases of adolescent PCOS,^[10] although homoeopathy has shown good results in treating PCOS in adults.^[11-13] Homoeopathic literature is comprehensive with various medicines for ovarian pathologies.^[14,15] In this case report, subjective and objective evidence with improved quality of life was documented. This case report follows the HOM-CASE Guidelines.^[16]

CASE REPORT

A 11-year-old, Bengali female child studying in 5^th standard was brought to the outpatient department of our hospital with the complains of with irregular menstruation since the menarche (Age-10-year old). She has been having irregular menstruation along with which she had been suffering from severe pain in the abdomen during menstruation. Flow was very scanty and dark in colour. The patient was having thick clotted menstrual flow and the menses were much delayed, appearing once every 6 months, all of which is suggestive of oligo-ovulation. Pain was bearing down in nature with pain in her legs. Leucorrhoea appears instead of menses in other months. It was acrid in nature and corroded the under garments. Weakness and nausea were the associated symptoms.

From history, she had suffered from mumps at the age of 4 years. Nothing particular in her family history was noted.

Diagnostic assessment

The patient was diagnosed with polycystic ovarian syndrome (2023 ICD-10-CM code is: E28.2)

Reasons:

1. USG findings suggest polycystic ovaries. [Figure 1]

2. As per Rotterdam 2003 revised criteria,^[17] the patient fulfilled all the three conditions required for the diagnosis of PCOS that are as follows: oligoovulation, hyperandrogenism and polycystic ovaries on USG.

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Figure 1:

(a) Ultra Sonography. (a) Before. (b) After.

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Therapeutic intervention

The selected homoeopathic medicine was administered orally. The potency, dosage and repetitions were made at the discretion of the physician.

The repertorisation sheet (Synthesis Homoeopathic Repertory Software, Version 2.1.7) considered for the prescription is shown in Figure 2.

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Figure 2:

Repertorisation chart.

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DISCUSSION

Tackling adolescent PCOS is making a way in unknown waters as it is a tough endocrinological disorder to manage due to unclear knowledge about pathophysiology, diagnostic criteria, and treatment protocols, limited studies being conducted, and difficulty in differentiating it with expected menstrual irregularities in pubertal period. Before diagnosing a case as PCOS with clinical features of androgen excess, such as hirsutism and biochemical hyperandrogenism, it is important to take into account whether oligomenorrhoea has persisted for a minimum of 2 years. If not so, other causes of androgen excess must be ruled out.^[2]

The main aim of the treatment lies in establishing regularity of menses with the improvement of other symptoms (acanthosis nigricans, hirsutism and acne). Monitoring changes in USG another way.^[24] The other facets that need to be considered by treating physicians are the presence of other medical conditions (Diabetes mellitus, abnormal uterine bleeding and infertility in adults), and psychological issues which also must be managed simultaneously.^[25,26]

Treatment protocols available in modern medicine include the use of Oral contraceptive pills alone or along with metformin and antiandrogen agents^[27] as per the individual requirement of the study. A study discussed the use of cyproterone acetate and ethinyl oestradiol for long-term in tackling effects of hyperandrogenism. The effects of the above mentioned conventional treatments are not instant but rather must be continued in the patient for a minimum of 6 months or more. A long treatment duration ensures less chance of relapse after the treatment has stopped. Thus, showing the requirement of continuation of treatment for a plausible amount of time even when conventional therapy is considered.^[28]

A study conducted on treatment-seeking behaviours in the case of PCOS revealed reasons such as less awareness about the condition, tolerance of disease and high economic burden partly due to investigations and partly due to treatment cost.^[29] The annual cost of treatment rounds up to 4.37 billion dollar in United State of America. These costs are considered the initial cost of investigation treatment and the costs are increased with association of diabetes mellitus, hirsutism, abnormal uterine bleeding and infertility. These costs do not include the cost of repeat investigations and cost of lifestyle intervention, which only add on to the previously mentioned economic burden.^[30]

The case presented is of an adolescent girl with premature menarche and a classical picture of PCOS. During therapy, the case improved progressively with respect to both disease symptoms and the general health of the patient. The case was managed with individualised homoeopathic medicine with lifestyle changes. Pulsatilla was the drug of choice for the case as it covered the totality of symptoms perfectly.

PCOS is a progressive lifetime disorder if not managed timely with worsening metabolic and physical symptoms. In the adolescent age group, the complaints of acne, hirsutism and obesity have serious implications as it has a grave effect on self-confidence and poor body image of the young girl.^[31]

In this case report, improvements were documented through different subjective and objective pieces of evidence. Improvement in the primary complaint and general well-being were assessed using the ORIDL scale at each follow-up visit.^[18] The ORIDL score eventually changed to positive (+3), indicating a significant improvement. Unbiased evidence was presented in the form of ultrasonographic findings. MONARCH^[23] was utilised to assess the potential cause attributions. The +8 score out of the maximum +13 score in MONARCH [Table 2], in this case, indicates a higher probability of a causal relationship between the homoeopathic intervention and the patient’s clinical improvement.

Homoeopathy is a gentle method of treatment based on strict principles of individualisation, which considers ‘the man in sickness’ and not just ‘the disease in man’, ensuring quality treatment is provided to every individual. The case report presented is a classic example of individualised treatment. The economic burden of the disease is much higher as it involves the cost of investigation, treatment and making modifications in lifestyle. Homoeopathy provides an additional benefit as cost of treatment is minimal even if the duration of treatment is of years duration. It also has an advantage of simplicity of treatment which does not involve addition of a greater number of medicines with each additional symptom making it easier for patients to adhere to treatment especially of adolescent age.

The case was followed over a period of 5 years and showed no adverse drug reaction or any untoward complication during the case management. The case also highlights the use of a placebo in homoeopathic practice correctly, as said by Dr. Stuart Close, being ‘the second-best remedy.’^[32] The treatment response was monitored mainly symptomatically. The USG findings have shown complete curing of pathology. The duration of treatment was 5 years, thus ensuring the complete removal of disease from the roots and ensuring that no relapse of the condition occurred. The primary limitation of this case report is the very long duration of treatment. The study provided the patient a good result, saving her the stigma of having hirsutism, acanthosis nigricans which can impair the social life of youngsters severely. However, the time involved in complete treatment was very long. The other limitation which can be considered in future is taking up a bigger sample size and demonstrating the effects of homoeopathic treatment thus generating higher levels of evidence. Case reports may be biased by the author’s experiences or beliefs because there are no control groups and few cases. On the other hand, in the field of evidence-based medicine, every level of evidence has considerably and effectively advanced clinical research. This case report’s information has been very useful, and by offering additional examples that are comparable to this one, we will be able to generate a hypothesis that could ultimately lead to more controlled and comprehensive clinical research.

CONCLUSION

The case provides a good insight in management of the case of adolescent PCOS. Homoeopathy as a science does not rely on the diagnosis for management of cases and this can be very well depicted in the case as adolescent PCOS is an unexplored area with respect to knowledge on pathophysiology and treatment protocols. It also depicts the nature and treatment of chronic diseases and how the treatment requires patience on part of a physician as well as patient. It also requires adherence on part of patient to the treatment as well as to diet and regimen changes which must be made in accordance with the disease. This case report necessitates taking up long-term interventional studies in case of polycystic ovarian syndrome with proper methodical rigor.