Since we are well aware of the serious impact of metabolic syndrome (DM, HT, obesity, hypercholesterolemia) on Obstetric practice, its effect on mother and fetus, pregnancy complications, need for interventions, intrapartum and postpartum period, it is now time to focus on its short term and long term implications on the reproductive health during the life span of a woman. About 30% of women presenting with gynaecological issues in day to day practice have Metabolic syndrome and its complications.
For ease of understanding, I have classified the impact of metabolic syndrome in gynaecology into the following headings.
Poly Cystic Ovarian Syndrome (PCOS) is also called metabolic reproductive syndrome. This syndrome has a huge spectrum of manifestations from the pre-pubertal stage to the post-menopausal stage. These are various heterogenic types of PCOS with different clinical presentations. Insulin resistance is the primary pathology. Hyperandrogenmia can lead to acne and hirsutism with a marginal elevation of male hormones. Anovulation can lead to irregular menstruation and subfertility. Diet and exercise are the mainstays of treatments with progesterone withdrawal bleed for irregular cycles. Subfertile women may need ovulation induction for conception and medications for DM if GTT is abnormal. They are at risk of GDM during pregnancy and type 2 DM later.
PCOS can lead to abnormal menstrual cycles due to an estrogen-progesterone imbalance leading to endometrial hyperplasia and cancer. Endometrial cancer seen in PCOS is well-differentiated with a good prognosis. The progesterone withdrawal bleed prevents the hyperplastic changes caused by estrogen in the endometrium. Early identification and treatment can cure this type of cancer completely.
Anovulatory heavy, irregular, prolonged menstrual bleeding is very common in obese women. This has a major impact on the quality of life often resulting in anaemia due to heavy menstrual bleeding. Addressing the cause of abnormal bleeding and optimizing weight can help maintain menstrual regularity.
There is enough evidence to prove that obesity can lead to sexual dysfunction in both females and males. Female sexual dysfunction is a common and multidimensional disorder related to a broad variety of biological, psychological and interpersonal determinants. The proposed hypothesis is that the endothelial dysfunction caused by metabolic syndrome can compromise the vascularity of the female genitalia resulting in arousal and orgasmic disorders.
Reproduction is an important process in human lives. Metabolic disorders can have adverse effects on both men and women’s reproduction by affecting their fertility. Metabolic disorders can affect women’s fertility directly or indirectly by interfering with the hypothalamic-pituitary and ovarian function. Metabolic disorders can cause hypogonadism. Hyperglycemia is also thought to affect ovarian function via advanced glycation products and receptors. The findings also indicate that obesity has a significant impact on female fertility as is evident from reports that show a high prevalence of obese women in the infertile population. A BMI > 30 is a major risk factor and many women spontaneously conceive after weight reduction. Subfertile women may need ovulation induction for conception and oral hypoglycemic agents for DM if GTT is abnormal. They are at risk of GDM during pregnancy and type 2 DM later.
Endometrial Cancer (Corpus cancer syndrome): This syndrome encompasses diabetes, hypertension, obesity and endometrial cancer. It is very important to highlight the risk of endometrial cancer and reinforce the preventive strategy by optimal control of weight, blood sugar and blood pressure.
Breast Cancer: Obesity is one of the major risk factors of breast cancer irrespective of metabolic syndrome. Screening for breast cancers is very difficult in obese women with excessive fat obscuring mammographic and sonographic findings. Women with dense breasts may need annual mammograms to identify early lesions.
Cervical Cancer: This is caused by the human papillomavirus, but the indirect association has been studied due to the poor glycemic control in metabolic syndrome women leading to persistence of HPV infection leading to Cervical cancer. More evidence is required for substantiating this. The routine screening for cervical cancer with PAP smear( liquid-based cytology) once in 3 years or dual testing with PAP smear and HPV DNA, once in 5 years is mandatory.
Ovarian Cancer: No direct association has been proven with Metabolic syndrome and ovarian cancer to date. Obesity, DM, HT are major surgical risks for staging laparotomy in women with ovarian cancer.
Women with metabolic syndrome need proper pre-op evaluation and optimal control of their metabolic parameters before any surgery. As we do most of our gynaecological surgeries laparoscopically, it is a great boon to obese women. Intra op anaesthetic risks, excessive bleeding due to hypertension, post-operative complications like infections, secondary haemorrhage, stroke and myocardial infarction are seen if health conditions are not managed correctly preoperatively.
A fast-track protocol has been developed to minimize the psychological stress and optimize the rehabilitation of patients. This procedure includes preoperative counselling, minimally invasive surgery where possible, bowel preparation as needed, goal-directed fluid management, a multimodal approach to pain management to reduce opioid use and early feeding and mobilization. This calls for a multidisciplinary approach and active patient participation in the complete process so that early ambulation, early recovery with less post-operative pain scores and a quick return to routine are achieved.
We follow a systematic checklist to ensure adequate hydration, ambulation, early enteral feeding, deep venous thrombosis prophylaxis and incentive spirometry (pre and post-op) to prevent pulmonary embolisms and atelectasis.
This is a very important aspect as many centres may not have adequate infrastructure to handle such high-risk obese women and may need to transfer patients to higher centres after complications arise. We need large operation tables, patient transfer stretchers, gowns for patients, long instruments and increased manpower to operate on such women. Multidisciplinary teamwork involving operation theatre teams, anaesthetists, physicians, cardiologists, gynaecologists, physiotherapists, dieticians and nurses are required for optimal care and recovery of such patients.
To conclude, Metabolic syndrome is an added stress to the woman with gynaecological issues and interferes with the management process to an increased extent. Many women can develop psychological disturbances due to both factors and need proper counselling and positive reinforcement. Some obese women may lose self-confidence and become depressed as their physical appearance may lead to self-recognition problems. We provide the needed reinforcement by greater psychological support from the medical fraternity and seek the support of family and friends to overcome this barrier of Metabolic syndrome.
Motivation for diet and exercise is the cornerstone of management by the entire team. It can be done by testimonials of patients who have achieved optimal parameters and by involving support groups, which will go a long way in making a difference in the lives of many women.
Dr Karpagambal Sairam Consultant Obstetrician, Gynaecologist and Fertility Specialist Kauvery Hospital Chennai
