Benign conditions of the ovary

Question 1

What is polycystic ovarian syndrome?

Answer 1

Polycystic ovaries

With hyperandrogenism, oligomenorrhoea

Question 2

Pathophysiology of PCOS?

Answer 2

Unclear of cause

Insulin resistance resulting in hyperinsulinaemia

This causes:

• excess androgen production by ovaries
• reduced production of sex hormone binging globulin by liver so more free testosterone

Question 3

What does sex hormone binding globulin do? Where is it produced?

Answer 3

It binds to testosterone, to reduce free testosterone in the blood

Produced in liver

Question 4

Presentation of PCOS?

Investigations?

Answer 4

Oligomenorrhoea
Hirsutism, acne, weight gain
Sub-fertility

Investigations:

Raised LH: FSH ration (i.e. LH raised, FSH normal) (helps to exclude ovarian failure where both would be raised)

Raised testosterone

Also check prolactin, TFTs, urinary 24hr cortisol
OGTT

TV USS to look at ovaries

Question 5

What’s the diagnostic criteria for PCOS?

Answer 5

Rotterdam criteria

2/3 must be present

• polycystic ovaries
• oligo or anovulation
• clinical or biochemical signs of Hyperandrogenism

Question 6

What’s the differential of oligomenorrhoea?

Answer 6

PCOS
Hyperthyroidism
CAH
Cushing's
Prolactinoma

Question 7

Why are women with PCOS at increased risk of endometrial cancer?

Answer 7

Because there is high levels of oestrogen

Question 8

Management of PCOS?

Answer 8

Weight loss

Metformin improves insulin resistance and menstruation

Clomifene citrate induces ovulation so used for improving fertility when she wants to conceive

Ovarian drilling: electrical stimulation of ovary to reduce steroid production

COCP

Anti-androgen for hirsutism and acne

Question 9

What are the long term consequences associated with PCOS?

Answer 9

Higher risk of gestational diabetes, type 2 diabetes, cardiovascular disease, endometrial cancer

Question 10

List the main benign ovarian tumours? Which is the most common.

Answer 10

Functional cysts (most common)
Endometrioma
Other cysts: mucinous, serous
Fibroma
Dermoid cyst (benign teratoma)

Question 11

What is the presentation of any benign ovarian tumour?

Answer 11

Asymptomatic
Chronic pain: dull ache, cyclical pain, dyspareunia
Irregular vaginal bleeding
Abdo swelling

Acute pain due to torsion, cyst rupture, haemorrhage

Question 12

What is an endometrial cyst? What’s another name for it?

Answer 12

Chocolate cyst

Endometrial tissue in ovary

Question 13

What is ovarian torsion? What causes it?

Answer 13

Twisting of ovarian ligament, causing rotation of ovary and occlusion of ovarian vein, there is oedema which then occludes the ovarian aftery

This cuts of blood supply to ovary. Infarction of ovary.

Ovarian cysts cause it

Question 14

Presentation of ovarian torsion?

Answer 14

Severe lower abdominal pain, vomiting

Pain improves after 24hrs as ovary dies

Question 15

In ovarian torsion, pain improves after 24hrs. Why?

Answer 15

This is when the ovary starts to die

Question 16

What are the ovarian causes of acute severe abdominal pain?

Answer 16

Ovarian torsion

Cyst rupture

Haemorrhage into cyst or peritoneal cavity

Question 17

What might you find on examination of a woman with a benign ovarian tumour?

Answer 17

Palpable mass

Vaginal discharge, bleeding

Question 18

Investigations of suspected benign ovarian tumour?

Answer 18

Check tumour markers

Trans-vaginal USS

Question 19

Who gets functional ovarian cysts?

Answer 19

Pre-menopausal women

Usually around 30

Question 20

Management of benign ovarian tumour (with no acute problem)?

Answer 20

Pre-menopausal:

• no intervention needed if its small and asymptomatic
• if it is big and symptomatic surgery cystectomy

Post-menopausal:

• calculate Risk of Malignancy Indexscore
• monitor closely or oophorectomy depending on risk

Question 21

How do you calculate the risk of malignancy index score of an ovarian tumour?

Answer 21

U x M x CA125 = RMI

U= USS score
M= menopausal status

Question 22

What is a fibroma?

Answer 22

Small solid benign fibrous tumours

Question 23

What is a teratoma?

Answer 23

Arise from primitive germ cells
Can be well-differentiated, with hair and teeth D:

Most often benign (in which case they’re called dermoid cysts)

Question 24

What’s a dermoid cyst?

Answer 24

A benign teratoma

Question 25

What’s the management of ovarian torsion?

Answer 25

Surgery immediately!

• remove ovary
• remove cyst
• untwist with view to remove later