B8.024 Cystic Ovaries Flashcards
ddx of RLQ pain with negative Bhcg
acute appendicitis gastroenteritis diverticulitis or perf crohns, UC ileus ovarian cyst tubo-ovarian abscess
acute appendicitis
pain around the umbilicus progressing to right lower abdomen
vomiting
fever
tachycardia
gastroenteritis
diarrhea vomiting abdominal pain lack of energy dehydration
diverticulitis/perf
abdominal pain nausea vomiting fever bloating or gas constipation
crohn’s or UC
abdominal pain
cramping
diarrhea
+/- blood in stool, fever, chills, fatigue, dehydration
ileus
abdominal discomfort loss of appetite feeling of fullness constipation inability to pass gas bloating excessive belching nausea/vomiting
typical ovarian cyst symptoms
lower abdomen pain, fullness or heaviness
bloating/swelling
severe pain before or after menstruation
dyspareunia
tubo-ovarian abscess
fever
chandelier sign
types of of ovarian cysts
functional cyst (follicular, corpus luteal) mucinous cystadenoma mature teratoma cancer endometrioma
what is an ovarian cyst
solid or fluid filled sac or pocket within or on the surface of an ovary
ovarian cyst epidemiology
common in all age groups
- most common among repro aged women
- > 3 mil per year
how are ovarian cysts diagnosed
transvaginal pelvic US
majority of ovarian cysts symptoms
physiologic
asymptomatic
follicular ovarian cysts
follicle fails to rupture
often resolves spontaneously
corpus luteum ovarian cyst
CL fails to regress
may produce progesterone
may be hemorrhagic
hemorrhagic ovarian cyst
blood filled follicular or luteal cyst
mucinous cystadenoma
lined by columnar epithelium
typically similar to endocervical epithelium
secrete thick gelatinous mucin
mature teratoma
dermoid
germ cell tumor
may contain ectoderm, mesoderm, endoderm derived tissues
endometrioid cyst
manifestation of endometriosis
endometrial tissue on ovary
chocolate cyst
clinically important parameters provided by transvaginal ultrasound
- determination of the presence or absence of relatively small masses (5-10 cm)
- determination of the origin of a mass (uterine, ovarian, tubal) and whether or not it has torsed
- detailed eval of internal consistency of cyst
- guiding transvaginal aspiration
- evaluation of endometrial or myometrial disorders related to pelvic masses
what are you looking for on US when examining internal consistence of a cyst
presence or absence or polypoid excrescences, septations, or internal consistencies (blood, pus, serous fluid)
appearance of mature teratoma on imaging
hyperechogenic interfaces on cystic mass
can have calcifications
appearance of simple/follicular cyst on imaging
thin smooth wall
anechoic contents
no or only few septa
no debris
appearance of typical endometrioma on imaging
thick wall
homogeneous low level internal echoes
occasionally wall calcifications
appearance of hemorrhagic cyst on imaging
fishnet weave/ fine reticular pattern
sign of clotting within the cyst
appearance of mucinous cystadenoma on imaging
thin septations
may demonstrate echogenic material (mucin)
similar to cervical epithelium
appearance of a potentially malignant cyst on imaging
thick > 3 mm septations
complex
how to rule out a torsion when looking at a cyst
doppler imaging
“ring of fire” appearance signifies NO torsion (blood flow still present)
how does the presentation of an endometrioma differ from a functional cyst
presents with chronic pain, not usually acute onset
what does periumbilical ecchymosis result from
retroperitoneal bleeding
in context of ovarian cyst: rupture
treatment of ruptured CL syst
surgical removal
exploratory laparoscopy
need exogenous progesterone support after surgery to prevent miscarriage
diagnostic workup for amenorrhea with hyperandrogenism
thyroid problems (TSH) rare enzyme defects (CAH) excessive stress hormones (cushing) tumors excessive growth hormone (IGF-1)
PCOS criteria
- polycystic ovaries
- high androgen levels
- irregular periods
appearance of PCOS on US
strand of pearls
12 or more follicles seen on ovary
clinical manifestations of high androgen levels
acne
hair
-loss: male patterned
-growth: face, chest, back
lab manifestations of high androgen levels
DHEAS
testosterone
abnormal menstrual cycles in PCOS
35 days or longer
heavy bleeding
problems with ovulation
PCOS causes
endocrine disruptors genetic differences in androgen receptor or sex hormone binding globulin (SHBG) gestational hyperglycemia in utero exposure to androgens
evolutionary paradox of PCOS
viability advantage
decreased fertility
treatment of PCOS acne
OTC: benzoyl peroxide, salicylic acid
prescription: topical/oral antibiotics, combined oral contraceptives, topical/oral retinoids
treatment of PCOS male patterned hair loss
topical minoxicil (rogaine) spironolactone - androgen receptor blocker combined estrogen and progesterone ketoconazole propecia (blocks DHT)
treatment of PCOS male patterned hair growth (hirsutism)
combined oral contraceptives spironolactone (6 months) propecia flutamide metformin laser therapy vaniqua (topical, 4-8 weeks)
systemic health problems seen with PCOS
heart disease obesity diabetes mood/sleep disorders cancer liver disease infertility
PCOS and heart disease
increased risk factors: 1. metabolic syndrome 2. high cholesterol 3. high blood pressure 4. obesity 3x increased risk: -stroke -heart attack
diagnosis of metabolic syndrome
3/5 risk factors
- BP >130/85
- waist circumference >35 in
- fasting glucose >100
- HDL <50
- triglycerides >150
relationship between PCOS and metabolic syndrome
21-40% of PCOS women have metabolic syndrome
half of this group is NOT obese
cholesterol abnormalities in PCOS
low HDL
high triglycerides
high LDL
treatment of high cholesterol in PCOS
statin: decreases cholesterol production
low cholesterol diet/excerise
high BP in PCOS
systolic >140
diastolic >90
risk of heart disease, renal failure, stroke
narrowed blood vessels from damaged lining increased pressure
treatment of high BP in PCOS
weight loss
smoking cessation
decreased alcohol use
BP meds: HCTZ, labetolol
obesity in PCOS
5-10% weight loss may:
- improve ovulation
- lower male hormone levels
- improve metabolic abnormalities
treatment of obesity in PCOS
diet
exercise
meds
surgery
relationship between PCOS and diabetes
increased risk of developing diabetes -11.9% in PCOS females > 30 -1.4% in non-PCOS females > 30 insulin resistance prevalence -40% in PCOS females
assessment of glycemic control in PCOS
no recommended screening test for insulin resistance
measure HbA1c
2h glucose tolerance
use of metformin in PCOS
improves body’s ability to process insulin
decreases androgen levels
improves ovulation but does not improve chance of live birth
1-4 pills/day
risk/side effects of metformin in PCOS
lactic acidosis
GI distress
weight loss
mood conditions in PCOS
30% have depression
34% have anxiety
sleep disturbances in PCOS
5x more likely to have sleep apnea
- periods of not breathing with sleep
- shortened sleep may lead to earlier death
PCOS and cancer
2-3x increased risk of endometrial cancer
-increased endometrial growth with anovulation
typical response to PCOS treatment
all symptoms improved after 6 months
spironolactone in PCOS
potent antagonist of androgen receptor
locks T receptors and decreases T production
