CHAPTER – I

INTRODUCTION
“Youth is like a fresh flower, age is like a rainbow that follow the storm of life; each has
its own beauty” - David Polis

Sexual health has been defined as “the integration of the somatic, emotional, intellectual, and
social aspects of sexual being, in ways that are positively enriching and that enhance
personality, communication, and love.”(WHO, 1975)

Sexuality is difficult to define because it encompasses so many aspects of our lives and is
expressed through a variety of behaviors. It is not only intrinsic to a person’s very being but
also extends into relationships with others. Intimacy and physical sharing are lifelong
biological and social needs. Knowledge about sex and discussions on issues of sexuality has
come to be recognized as important and necessary for human development.

Human sexuality is not merely a biologic phenomenon, but one that pervades the total person.
From the moment of conception, a variety of factors come into play to influence our sexuality
not only as children but also as adults. Being born with female or male genitalia and
subsequently learning female or male social roles seem to be key ingredients; yet this does
not explain all variations of sexuality and sexual behavior.

Both female and male infants are born with capacity for sexual pleasure and response. With
stimulation, the males respond with penile erection and the females with vaginal lubrication.
The child from age 1-6 solidifies the sense of gender identify and begins to differentiate
socially defined gender appropriate behavior. For children from 6-10 yrs of age, education
about and re-enforcement of sexuality come from parents and teachers; but more significantly
from the peer group.

The onset of puberty in girls is usually signaled by the development of breasts. Raising
levels of estrogen also begin to affect the genitals. This may be the age of identifying sexual
orientation. Adolescence may be the first time the child seeks health care without parental
accompaniment. Adult has gained physical maturation but continues to explore and define
emotional maturation in relationships.

Attitude towards sexual feelings and behavior change as people develop and as they grow
older. Because wellness includes sexual health, sexuality should be part of a health
care programme. Yet sexual assessment and interventions are not always included in
health care. There are many illnesses that alter physiologic process essential to the
sexual function.

One of the most common endocrine disorders among adolescent girls which alter the sexual
function is polycystic ovarian syndrome (PCOS). Polycystic ovarian syndrome was
originally described in 1935 by Stein and Leventhal as a syndrome. It is not a single entity,

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but rather the end result of several conditions. This heterogamous disorder is characterized
by excessive androgen production by the ovaries which interfere with the reproductive,
endocrine and metabolic functions and this syndrome is manifested by amenorrhea, hirsutism
and obesity, associated with enlarged polycystic ovaries.

A more appropriate name of the symptom complex would be the continuous estrus syndrome,
since the hallmark of the condition is anovulation and unopposed estrogen stimulation.
Women with polycystic ovarian syndrome (PCOS) have been found to report an increase in
problems with sexual function. The concern about lowered fertility in some women with
polycystic ovarian syndrome may also impact sexual function in women who are trying to
conceive.

Most women with polycystic ovarian syndrome have reported that this condition impacts
their sexual relationship and creates less satisfaction. Some of the common symptoms of
polycystic ovarian syndrome such as weight gain, acne, low self-esteem, fatigue and male
pattern baldness, negatively affect sexual health and creates diminished self-esteem, which in
turn lessens sexual confidence and arousal.

Women with polycystic ovarian syndrome also have a greater risk of miscarriage,
hypertension during pregnancy, poor cardiovascular health, and diabetes. Although, sexual
health seems less important than this more serious health conditions, it can still contribute to
a reduced quality of life in a significant way and is a key sign that your body is out of
balance. In general, women with polycystic ovarian syndrome report less sexual satisfaction
than women without this condition.

BACKGROUND OF THE STUDY

The incidence of polycystic ovarian syndrome is approximately 5-10% making it the most
common endocrine disorder in women of child bearing age and accounts for about 75% of
anovulatory infertility. The prevalence of polycystic ovarian syndrome greatly depends on
the criteria used to define it.

Swanson et al. were the first to provide an ultra-sonographic description of polycystic ovaries
(PCO). Using such ultra-sonographic description, 22% of unselected women have been
reported to have polycystic looking ovaries. However, this marker is relatively nonspecific
as 25% of patients with polycystic ovary on sonography, had regular menstrual cycle.
Moreover, not all patients with hyper androgenic ovulation demonstrate polycystic looking
ovaries.

Recently, a study by National Institute of Health / National Institute of Child Health and
Development (NIH /NICHD) has redefined the criteria using ultrasound, clinical, as well as
biochemical means. According to the new criteria, the prevalence of polycystic ovarian

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syndrome was found to be 40% in a population of 369 unselected women of reproductive
age.

Nearly 60% of women with polycystic ovarian syndrome experience some sexual
dysfunction, according to a study published in the Iranian Journal of reductive Medicine.
The researchers also noted that polycystic ovarian syndrome and sexual issues go hand in
hand; and they are likely to be the result of women developing body issues that come with the
syndrome.

There are theoretical reasons to suspect that women with polycystic ovarian syndrome have
an increased risk of cancer related to hyperinsulinemia and accelerated cell growth / division.

NEED FOR THE STUDY

Polycystic ovarian syndrome is a problem with hormones that affects women during their
child bearing years (15 to 44 yrs.). Between 2.2 to 10.7% of women in this age group have
polycystic ovarian syndrome.Many women have polycystic ovarian syndrome but don’t
know it. In studies, up to 70% of women with polycystic ovarian syndrome hadn’t been
diagnosed.

The emotional and physical consequences of polycystic ovarian syndrome appear to be

increased risk of infertility, cardiovascular disease, carcinoma of: ovaries, endometrium, and
breast, hypertension, etc.

The symptoms of polycystic ovarian syndrome often begin in adolescence, and the rising
prevalence of peripubertal obesity has shown that prevalence and severity of adolescent
polycystic ovarian syndrome is increasing in parallel. Recent data have disclosed a high
prevalence of hyper androgenemia among peripubertal adolescents with obesity, suggesting
that such girls are indeed at risk for developing polycystic ovarian syndrome. Adolescents
with polycystic ovarian syndrome are at risk for co-morbidities such as, metabolic syndrome
and impaired glucose tolerance; and concomitant obesity compounds these risks. For all these
reasons, weight loss represents an important therapeutic target in obese adolescents with
polycystic ovarian syndrome.

Polycystic ovarian syndrome is exceedingly common.When defined by the “National

Institute of Health (NIH) criteria”, the prevalence approximates 7% in adult women.But the
apparent prevalence may be double, when using recent diagnostic criteria that incorporate
ovarian morphology. Polycystic ovarian syndrome is a major cause of sub fertility, and it is
associated with metabolic syndrome, and type 2 diabetes and obesity. For these reasons,
polycystic ovarian syndrome represents major women’s health and public health issue.

It has been recognized for many years that women with polycystic ovarian syndrome have an
increased risk of endometrial adenocarcinoma. Conventional thought has argued that the
association between polycystic ovarian syndrome and endometrial cancer is the consequence

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of anovulation: estrogen unopposed by progesterone acting on the endometrial to promote
proliferation, hyperplasia and ultimately, neoplasia.

A recent population based case control study identified a 2.5 fold increased risk of epithelial
cancer of the ovary in women with the syndrome. A study of prevalence of polycystic
ovarian syndrome in women with strong family history of ovarian cancer showed no excess
compared with female controls, confirming that the excess risk of ovarian cancer in
polycystic ovarian syndrome is relatively modest.

A study of causes of death in women with polycystic ovarian syndrome revealed a

standardized mortality ratio for breast cancer of 1 in 48. Again, this is relatively modest;
further study is required to clarify this.

One study of endometrial sampling of 50 pre-menopausal anovulatory women with

polycystic ovarian syndrome showed that 2 had hyperplasia. The life time risk of
endometrial cancer for these women is not known, but the excess risk is likely to extend well
into the menopause.

Early diagnosis and initiation of lifestyle changes can have a positive impact on the risk for
long term complications. According to a comprehensive review, the calculated ovulation rate
of 84.2% and a pregnancy rate of 55.7% were obtained after laparoscopic ovarian drilling,
hormonal therapy, lifestyle changes, dietary medication etc. in patients with polycystic
ovarian syndrome.

Adolescents with polycystic ovarian syndrome experience lower quality of life compared
with healthy adolescents. Most important of all, it is the patient’s perceived, rather than the
clinician’s assessed severity of illness that negatively affects the quality of life. Patients
noted a greater change in their overall health compared with the health of peers.The timing of
diagnosis and initiation of treatment, variability in treatment approaches, and patient’s health
care provider communication may also be instrumental in understanding the long term health
and quality of life outcomes in adolescents with PCOS. There is a need to develop
supportive interventions that address quality-of-life issues to reduce the distress that patients
with polycystic ovarian syndrome may face as adolescents and young adults.

The gain in knowledge regarding polycystic ovarian syndrome will help the adolescent girls
to identify the signs and symptoms and diagnose the condition at an early stage.