Medical question #2. Ovarian cysts. – Part 2

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Polycystic ovarian syndrome is a little bit different animal actually. Here is some genetic predisposition.

Classically: an overweight young female presents with oligomenorrhea or amenorrhea, anovulation, acne, hirsutism, and or infertility.

What is what? Poly = many. Many, many, many men.
So PCOS means bunch of those bubbles in the ovaries. The follicles did not rupture on time, as they should. Oligo means a little. Meno is derived from menses. Rrhea means flow in Latin

So olygomenorrhea = flowing a little bit (less than it should).
A- is a prefix that means “No”. So, amenorrhea = no flow at all.
Hirsutism. I don’t remember where it came from, but means hairy or hairiness. Actually excessive hairiness.

Causes of PCOD or PCOS (disease or syndrome) are obesity, genetic predisposition and some other causes of Luteinizing hormone (LH) excess.

There is a self-amplifying cycle:

LH stimulates theca lutein cells. Theca means sort of capsule. Doesn’t really matter, just an anatomical term.
Those cells are special. They produce androstendione and testosterone. Androstendione and testosterone are actually male hormones. You know, bodybuilders use these hormones to get muscle bulk. You probably heard about those hormones. Sport doping uses testosterone.
So, athletes build their muscles and trash their liver.

Rumors say that a famous Hollywood actor used the hormones. Later he got liver transplant.
Though he always denied the use.

Anyway, female body converts androstendione into estrone (a weak estrogen). Fat cells do this. Estrone is a female hormone already.

Basically any body produces androgens (andros = man) and estrogens (female hormones). Just the proportion of those hormones makes us male or female.

The cycle happens in normal person as well.

The estrone stimulates pituitary secretion of LH.
Pituitary is a small gland in you brain. Pea Size.
It’s small, but it sooooo powerful.

Pituitary has another name – hypophysis. Hypo means down, phys means growth, so this gland is growing from below the rest of the brain. Pituitary gets bunch of connections from hypothalamus.
Hypothalamus means “below thalamus”.
These two areas of brain regulate almost all the hormone production in organism.

Higher levels in brain hierarchy regulate them.

Hypophysis gets a command. Then it produces some intermediate messengers and hormones.
The hormones go into blood and control whole body.

Hormones are like orders, like messages to the rest of the body.

Brain may give quick orders: Signals go through the nerves. It is like a phone order or cablegram.

Brain also regulates organism through the hormones. This is like a mail order.
Sort of if the brain sends letters by regular mail. The hypophysis is the Post Office in this case.

PCOS kicks in when a woman is obese. There are more fat cells to convert
androstendione to estrone. Estrone has such effect that it stimulates pituitary secretion of LH.
LH in its turn goes back to those theca lutein cells we discussed and turns them on again, to produce more androstendione, which is again converted into estrone.

Self-amplifying cycle

In addition, that increased level of testosterone causes the hirsutism (she becomes hairy like a male) and acne in female.
In a normal person this cycle is probably designed to support the development of fetus.
Estrogen helps placenta to grow. Placenta supports fetal growth.

However, in a person with PCOD the cycle is going out of normal control. In this case LH causes growth of the cysts in the ovaries.

Why?

Because the corpus luteum cyst is partially made by overgrowth of those theca lutein cells. LH stimulates theca lutein cells.

Also, women with PCOS have intolerance to glucose (sugar) and resistance to insulin.
It means there is a lot of insulin (hormone that helps to utilize glucose mainly).

However excessive insulin does not work. Either receptors to insulin do not work or something else, but the glucose is not utilized. Hence, energy inside the cells drops. Hence, a big pile of other problems mounts. As if it is Diabetes Mellitus. Diabetes is a different topic of discussion. For us, it is worthwhile to mention that people with diabetes are very much prone to any infection.

PCOS causes acanthosis nigricans also. Acantocytes are special skin cells.
Nigricans means black in Latin. That thing looks like thickened pigmented skin. When you touch it, it feels like velvet. Usually it happens in axilla, neck, below breast, in inner thigh and vulva. So, mostly all those places where skin folds.

The treatment for PCOS includes different medications: oral contraceptives, progesterone,
glucocorticoids, ketoconazole, spironolactone, cyproterone, flutamide, cimetidine, finasteride, ovarian wedge resection, laparascopic electoracutery, mechanical hair removal, etc.

All methods break the cycle of overproduction. The medications are either hormones themself or hormone-like substances that occupy receptor site and prevent regular hormone to work.

The medications act on different levels. Normal hormones have very complicated regulation. There are loops and feedbacks in the pathways.

To suppress a hormone production or action, you give similar hormone or another hormone or non-hormone at all, that goes to the feedback loop and breaks it and so on. It’s really long separate discussion.

Basically, you either decrease hormone production or shift ratio toward female hormones.

Another way, the best probably, is weight loss. No fat cells – no conversion of andrgoens etc… You can make conclusions yourself.
It’s the first line of treatment.

For a simple follicular ovarian cyst (not PCOS) doctor rules out ectopic pregnancy. Then he may send patient home and repeat pelvic exam in 6-8 weeks. Especially, if the cyst was small, less than five cm in diameter.

For larger cysts, doctor would order pelvic ultrasound.

Most follicular cyst will resolve on their own in six to eight weeks. Though, a physician may give oral contraceptives. Again, this suppresses stimulation of cyst by hormones from the hypophysis. The hormones are named gonadotropins.

If the cyst is still there after 6-8 weeks, a suspicion arises that the cyst maybe malignant. Then doctor orders other studies. CT scan. Physician may perform surgical procedures also. He looks what is this cyst really.

Corpus luteum cyst is usually not treated. However, oral contraceptives may be used.

Rupture of any kind of those cysts leads to another story. Acute pain, bleeding into peritoneum.
Sometime bleeding is very severe and is true emergency. You need also to distinguish other process in the abdomen. For example, appendicitis looks similar. You can treat mild case of non-complicated cyst rupture with just observation. Appendicitis almost always requires surgery.

There are many other problems arise. Surgeon scratches his head: what’s going on? Is this this or is this that? Here is the CT scan gives big advantage.

Now, going back to the question of Ms. L.

If the cyst was infected, I don’t’ see a reason why a ruptured cyst wouldn’t become infected.
Cyst content is very nutrient-rich. Remember? All those cells and their products are dedicated to feeding the oocyte (future baby). Should be very tasty for any bacteria.

Rupture may cause significant bleeding as well. This blood is also different from the blood in your vessels.

This blood is sitting in the pelvis, not moving, quickly clotting. Clotting prevents entry of white blood cells. “No flow” prevents entry of antibodies. Absence of flow prevents entry of other protective chemicals (complement etc).

So, it is very nutrient-rich media for bacteria growth.

They can go wild. Why not?
If a female had another pelvic infection before, that infection can flare up. In a normal person peritoneal cavity should be sterile. However, any gynecological or gastrointestinal infection may supply bacteria. Now, mix these bacteria with the content of the leaking cyst. It just destined to become infected.

Actually Ms. L later answered her own question in another e-mail. She had cysts multiple times and they became infected several times.

So, to answer the question:
Will the ruptured cyst become infected? Not necessarily. Rather not. Can it become infected?
Yes.

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Author: Piyawut Sutthiruk

Losing weight will keep you healthy and have a long life. Cheer Up!
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