What Ails Women

An alarmingly large number of urban Indian women are reporting a similar set of ailments. What’s up?

In explaining endometriosis to her, TV host Padma Lakshmi said her doctor told her, “It’s like roots in a garden and the roots can spread everywhere. If you don’t [treat it], it will ruin the whole flower bed.” Twenty-seven-year-old South Mumbai resident Laila N is not quite so metaphorical. She says the pain of endometriosis was so bad “it felt like someone was trying to pull my ovaries out”.

Her problems first began at 16 when, at about 72 kg, she was diagnosed with polycystic ovaries; she battled through throbbing, irregular menstrual cycles, and had a pain-fuelled temper her friends knew enough to stay away from. The weight was shed, and her ovaries cleared, but the pain was consistent.

Then she was diagnosed with endometriosis, a condition in which tissues that normally line the inside of the uterus grow outside it. Doctors are still unclear about the cause of the complication; genetic predisposition, immunological problems, and impaired or delayed fertility have all been blamed for this medical enigma. After a laparoscopic surgery in late 2008 and continued treatment, the 5’4" banking professional has been cleared of both conditions, but Laila’s always watchful. If there’s one consolation to what is bound to be a life-long vigil, it is that she knows her friends understand: “Out of my circle of 15 friends, four have polycystic ovaries and one has a thyroid condition.”

Used to be that girls grew up, became women, got married and delivered children; their gynaecological health was barely discussed and needed little medical oversight. Babies were born ‘natural’, stretch marks were a mark of solidarity, and a C-section was an avoidable aberration.

Today, that’s an improbable fairy tale for young urban women like Laila. They face a compendium of rising hormonal and gynaecological problems like endometriosis, polycystic ovarian disease (PCOD) and thyroid dysfunction, especially hypothyroidism. Look around, ask a few of your female friends, and the numbers will add up. Women, younger and younger, working and stay-at-homes, are getting sick. Not with mortal diseases, but with the aches, pains and disfigurations that affect the quality of their life, and their emotional stability. As the Martians would say, it’s their hormones.

Medical representatives and pharmacists report that oral contraceptive pills like Tarana, which is prescribed for endometriosis; Metformin, which increases insulin sensitivity in women with PCOD; and anti-obesity drugs have become bestsellers. Indian women are reaching out to companies like Insulite Labs, an American health-support company that combines drug, diet, and exercise into a system that helps manage PCOD and diabetes. In the central laboratory of Thyrocare, the largest thyroid-testing company in India, only male technicians work the night shift when blood samples collected from 660 collection centres in 33 cities are tested for a number of illnesses. But, you can’t miss the female presence in the room. The highest number of thyroid investigations done by Thyrocare on any given night is of women’s samples, most of which test positive for some thyroid-related ailment or the other.

“Women in cities, even smaller ones which now behave like the metros, have these problems,” says Dr Nozer Sheriar, a prominent Mumbai-based gynaecologist and author of several books on the subject of female ailments. “Overall health and life expectancy has improved, but when you look at the urban woman, there is no question that something is happening. There is anecdotal evidence that the incidence of these diseases has increased.” The evidence is in the telling, as it is difficult to source trustworthy data on these illnesses.

According to some reports, PCOD now affects up to 40 per cent of Indian women—including teenagers—in their childbearing years. That figure shoots up to 90 per cent among obese women. “These women (with PCOD) tend to have more oestrogen, the female hormone, but also more androgen, the male hormone, and they end up having cosmetic problems like hirsutism (excessive hair growth), male-pattern baldness, menstrual problems, and long-term metabolic problems like diabetes and hypertension,” says Dr Sheriar.

Dr Nadeem Rais, one of Mumbai’s most respected endocrinologists, says that in over 25 years of practice, PCOD has become the top lifestyle disease among women. “In the 1980s, I would see one patient with it in one or two months, in the late 80s, it became three or four per month, now there are at least seven a day, all women between the ages of 18 and 30,” says Dr Rais.

A close second on the complaint chart is thyroid disorder. Last year, the Indian Thyroid Society, based in the Amrita Institute of Medical Sciences in Kochi, hypothesised that more than 40 million Indians suffer from thyroid disorders, of which, 60 per cent they said are women with hypothyroidism caused by an under-active gland. When the thyroid hormone in the body is low, patients experience a clutch of non-specific symptoms like fatigue, weight gain, depression, constipation, etcetera. Many of these problems are hormonally inter-connected so it’s not unusual for a patient to have one, two or even all three complications. Case in point: 30-year-old Mumbaikar Rita. Her medical flowchart went from depression to hypothyroidism to PCOD.

The rituals of womanhood have changed drastically in the last decade. Women ‘shop’ for gynaecologists with about the same particularity they reserve for finding a mate; the annual pap smear and blood workup are key appointments on their yearly schedules; and finding the best oral contraceptive pill (OCP) is as important as locating the right job. Women today are more vigilant than their mothers were, and better lookouts rack up larger numbers.

For one thing, doctors say women have bought the myth of a flawlessly scheduled menstrual cycle as a sign of normalcy. “It was only after the advent of modern contraception about 50 years ago that women gained control over the processes of their body. Historically, a woman didn’t menstruate a lot because she was always either pregnant or lactating,” says Dr Sheriar.

And pregnancy afforded women some calm from the painful processes of a disease like endometriosis. “Pregnancy disrupts the prolonged exposure to oestrogen stimulation,” says Dr Sheriar. Though oestrogen is the female hormone, it can cause a lot of these problems, while during pregnancy, progesterone takes over as the predominant hormone in the female body. So as retrograde as it sounds, at some point in treating an endometriosis-affected woman without children, most doctors also prescribe a baby as part of the treatment package, which also includes surgery, and progesterone-only OCPs.

Psychiatrists blame the superwoman syndrome, or as the actress-model Jerry Hall once quipped, the need to be “a maid in the living room, a cook in the kitchen and a whore in the bedroom”. Plus, now, a successful worker in an office. Dr Sheriar calls this contemporary group of 20- and 30-something women the “in-between generation”, which is required to be traditional and modern at the same time: pick up a laptop but also the soup ladle. Couple that with the stress of family complications, the weight of unhealthy eating habits (weight gain is a major factor in the onset of PCOD), high levels of chemicals and hormones in the food system, and an already complicated hormonal system starts to act like a catatonic, three-headed monster.

According to the 2001 census, some 27 per cent of urban women are now in the workforce, and as this figure rises, so do the ills that plague them. Seventy per cent of patients with fertility and hormonal complications at Mumbai’s government-run JJ Hospital are working women. “They work at home and in office and feel inadequate in both,” says Dr Ashok Anand, the head of JJ’s gynaecology department. Women like 25-year-old PCOD outpatient Mansi Yadav, who’s been trying to get pregnant since the first year of her five-year-old marriage. She works from 9.30 am to 6 pm six days a week at a Thane-based pension fund consulting firm, and at a height of 5 ft, weighs just about 45 kg.

In 43-year-old Ujjwala’s home, her transformation from nurturer to patient demanded that her husband evolve as well. About a decade ago, shortly after relocating to Abu Dhabi, the mother-of-one was diagnosed with PCOD. It sensitised her husband Sandeep to the effect stress has on women. “We’d never heard of PCOD at that time, and at first when she had hair growth on her face, I thought she was just being too conscious. She might disagree, but I think she got it because of the stress of moving to a new country,” says Sandeep, who is currently a Mumbai-based senior vice-president at an infrastructure development company.

The couple’s daughter is about to turn 18, and Sandeep feels it’s high time Nisheeta picks up stress-management techniques so that she can one day achieve that elusive work-home balance. “Given the financial traumas that families nowadays have, it is not possible for women to not work, so what they need is a check list of problems they may face in the workplace and practical coping mechanisms.”

Even men younger than Sandeep have mastered the dictionary of hormonal troubles. Laila’s never had a problem explaining endometriosis to male friends because many of them have mothers, siblings or friends with the condition; 26-year-old journalist A Mehta says her boyfriend easily understood her PMS and pain-induced mood swings because his mother went through it. In fact, her mother was far more traumatised. “Once we left the doctor’s office, she was very upset so I joked that if I couldn’t have kids then I’d just get a dog. That didn’t help,” says Mehta.

Many mothers struggle to understand a problem they never faced, especially because it questions the very essence of being a woman. Having said that, proper treatment takes care of most of the fertility issues faced by endometriosis and PCOD patients. But if time is the only thing they have on their side, 24-year-old PCOD subject Archana Rokade’s mother would prefer she use her ace card as fast as possible. “I’m taking her to an Ayurvedic doctor soon, I have also heard acupressure is good. It should be solved so that she can get married fast and have babies before it is too late,” says Surekha Rokade.

In her predominantly Maharashtrian housing estate on the grounds of JJ Hospital, Archana is a familiar, confident and ebullient personality. People call out to her when she’s walking around—she’s got plenty of friends and bright prospects. But two years ago, the relationship she had based her marital dreams on floundered and she says the stress of the break-up left her several kilograms lighter. Rita, who has eventually diagnosed with hypothyroidism and PCOD, gained 10 kg and suffered a severe bout of adult acne.

The root cause of all the seemingly random symptoms is stress. When women experience stress, whether physical or emotional, their hormones go into overdrive, this much we know, but how does it produce sideburns on a woman’s face, shoot a 65 kg-woman to almost 80, or make an otherwise peaceable copywriter so angry she wanted to literally kill everyone who spat on the road? The answer lies in the hypothalamus.

The hypothalamus, a hollow funnel-shaped area of the brain, which Louann Brizendine in her authoritative book The Female Brain called ‘the conductor of the hormonal symphony’, controls the way the body receives messages regarding food, weight, satiation, thermo regulators and mood. Situated above the pituitary gland, and part of the endocrine system, it is the region of the brain that governs everything.

“When hormones get affected due to stress, they affect the hypothalamus, and then all these messages get mixed up,” says Dr Rais. “Everything is first psychic, in the mind, then psychosomatic, or mind and body, then somatic, the body, and eventually organic.” Thus the aggrieved hypothalamus releases peptides, which regulate certain areas of the pituitary gland and the adrenal cortex—and these two in turn release hormones that go and affect other functions.

Most people don’t even realise they’re stressed. Diarrhoea, headache and disturbed sleep patterns are short-lived symptoms. But stress has a long-term influence on the body, especially on women. Along with genetic and environmental factors, biological change wrought by hormonal fluctuations is one of the main causes of clinical depression, which is in itself a stress on the body and can affect an individual’s ability to recuperate from illnesses.

“The most common conditions associated with hormonal disorders are depression and anxiety, especially clinical major depression which is high among women,” says Dr Shamsah B Sonawalla, associate director of psychiatry research and consultant psychiatrist at Mumbai’s Jaslok Hospital. “It’s an established fact that even without any underlying illness, women get clinical major depression two to three times more often than men, and it is the number one illness among women around the world across rural, urban and economic divides.”

A quick scan of your daily city news is a pretty good indicator of how impromptu complications push fragile women off the edge: in February, a woman in Kolkata killed herself and her children because of a fight with her in-laws; in March, a Mumbai-based airhostess jumped to her death because her boyfriend refused to let her smoke; the same month, a 32-year-old immolated herself because her 9-year-old daughter refused to study.

In general, men have a hormonal advantage because their hormonal system is one steady and continuous process whereas for women the monthly cycle changes their hormones everyday. It is only when it comes to fertility that they fall behind. “There is enough evidence to show that while PCOD, endometriosis and fibroids are increasingly see causing infertility there has been an even more dramatic increase in male factors causing infertility,” says Dr Sheriar. From oestrogen-infested pollutants in the drinking water to stress and smoking, the last 25 years have seen a disastrous decrease in sperm counts.

For people who know the signs, women with PCOD and hypothyroid disorders are marked. With obvious weight gain, erratic hair growth and male-pattern baldness among the symptoms, many doctors say they know a PCOD patient just by sight. It takes a combination of measures to deal with the supplementary and cosmetic complications of these illnesses.

“Just when you think one problem is done with, another one will show up. You have to remember that it could have been worse,” says Mehta, who has just found out that she has high levels of insulin in her blood. As for babies, “Let’s face it, we’ll need a plan,” says Mehta.

Sanitary napkin marketers tell us we can jump, hop and skip right through our menstrual cycle and still feel fine, and we tell ourselves that we can do the work thing, the mother thing, the wife thing, the daughter-in-law thing and the lover-thing, all in one good-looking, fit, emotionally stable package. It was never going to be that easy.

And if you have to live with it, there are excellent treatments, even reversal methods for these complications. Contemporary OCPs can reduce the risk of endometriosis and treat the cosmetic signs of PCOD; there is a range of injections and medications which don’t cause side-effects; and surgery is minimally invasive, more effective and less painful. “The number one goal in primary prevention is to manage weight. If you do that then you prevent diabetes, PCOD, and lower the risk of uterine cancer, and many other metabolic problems,” says Dr Sheriar.

All the women in this story have learnt that lesson, and together with corrective treatment, regained a semblance of control over their bodies. For a package treatment option that heals emotional scars and physical damage, experts suggest yoga. “Bodies and emotions are interlinked. With yoga, you slowly get the ability to be indifferent,” says Rajvi Mehta, an Iyengar yoga teacher with a doctorate in reproductive physiology. “Asanas [special bodily postures], although done by the body, aid you to be in control of your emotions.”

Last year, in Yoga Rahasya, a publication of the Ramamani Iyengar Memorial Yoga Institute, 36-year-old Uma Iyer from Bangalore wrote about how she was able to beat PCOD through yoga asanas she learned at the Iyengar institute in Pune. Iyer developed polycystic ovaries after a difficult miscarriage in 2002. In addition to the weight gain, depression and hair loss, Iyer had a demented menstrual cycle: she’d go through months without a period, but once it started, the tsunami would last up to 45 days. “I got to a point where I would have to carry pads wherever I went, and because of the weight even stitching a blouse was traumatic,” says Iyer. “When I decided to try yoga, I was desperate.”

But, four years later, the former aerobics student says yoga changed her life. At their Pune institute, guru BKS Iyengar and his daughter Geeta taught Iyer asanas to relax her rigid pelvic region—they improved blood circulation, and importantly, brought hormonal balance. Most of it made her yelp in pain, but she says the improvement was far more important. According to Iyer, after a year-and-a-half of continuous practice, sans medication, her appetite returned to normal, the carbohydrate craving vanished and she lost several kilos. And the anger dissipated. “When you’re focused on getting an asana right, you become calm and stop thinking of everything else. Most importantly, you feel in control.”

Last year, while campaigning to get her husband elected, Michelle Obama spoke about the guilt that all women hold in their hearts: “That guilt that you don’t have the choice to stay home, and even if you do, you feel guilty”.

Many experts have also labelled guilt a women’s disease—the perpetually nagging feeling that they’re either shortchanging themselves or their families. So, a sense of control, even in the ability to maintain a sarvangasana, can be a mood elevator. Soon enough, your hypothalamus will thank you.

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