Disorders of the Ovaries and Fallopian tubes: Ross Flashcards
MOST adnexal masses are discovered _______
incidentally
**Clinical Challenge is distinguishing benign vs. malignant
disorders of the ovaries and oviducts (Fallopian tubes):
Consider age groups->
young women:
- majority of ovarian cysts benign; hemorrhagic corpus luteum, follicular cysts, and dermoid cysts
- Tubal abnormalities including ectopic pregnancy and tubal infection
disorders of the ovaries and oviducts (Fallopian tubes):
Consider age groups->
Postmenopausal:
when majority of ovarian or tubal cancers occur
Evaluation of adnexal mass: includes?
-History: Age, Previous Hx, Acute/chronic, Family hx
-Physical exam:
Tenderness, peritoneal signs
- Labs: CBC, Tumor Markers
- Imaging: U/S, CT, MRI
- Final dx–> bx
DDx of adnexal mass
-benign:
ectopic pregnancy, pyosalpinx, ovarian cyst, tuboovarian abscesses, adnexal torsion
DDx of adnexal mass
- Cancers:
epithelial ovarian cancer, germ cell cancers and stromal cell cancers
Because hard to distinguish these masses should be evaluated with:
Hx, PE and imaging typically **US first
Benign adnexal masses are common in women during ________
*reproductive age and are caused by physiologic cysts
A 25 year old woman presents to you for routine annual WWE. She has had two routine vaginal deliveries and is otherwise healthy. She smokes 1 pk/day, has no GYN complaints. LMP 3 weeks ago.
PE: Left ovary enlarged to 5cm in diameter.
Which of the following is the best recommendation to this patient?
A. Order CA-125 testing
B. Order outpatient diagnostic laparoscopy
C. Order ultrasound
D. Order a CT scan of the pelvis
Admit to the hospital for exploratory laparotomy
C. Order ultrasound
Functional Cysts:
-normally the ovaries grow _____ each month
follicles
–*Follicles produce the hormones estrogen and progesterone
Follicles release an ____
egg when you ovulate
Sometimes a normal monthly follicle keeps growing, When that happens, it is known as a _______
**functional cyst
There are two types of functional cysts:
list
- Follicular Cyst: failure of ovulation
- Corpus Luteum Cyst
Which type of functional cyst is MC?
**Follicular cyst=Failure in Ovulation– most likely 2/2 disturbances in the release of pituitary gonadotropins.
- **Common
- Failure to Ovulate and fluid fails to be reabsorbed
Follicular cyst:
- Diameter ?
- Histologically they are lined by an inner layer of ______
- vary in diameter, 3-8cm
- granulosa cells and an outer layer of theca interna cells
Follicular Cyst:
-Sx?
- Typically, asymptomatic
- Large cysts may cause aching pelvic pain, dyspareunia, and occasional abnormal uterine bleeding
Follicular Cyst:
-complications?
**ovarian torsion and bleeding
Follicular cysts:
-tx?
- Watch and Wait
- Usually Disappear spontaneously in 60 days without tx
- Reevaluate in 6 weeks by US
- Benign vs. Malignant
- Surgical evaluation
- OCPs often recommended to help establish normal rhythm, but more recent studies show may not produce more rapid resolution than expectant management
Corpus luteum cyst= thin walled _______ cysts that forms after ______
- **unilocular
- ovulation when corpus luteum fails to regress
Corpus luteum cyst:
- average size?
- how common?
- 3-11 cm in size (considered a cyst >3cm)
- Much less common
Corpus luteum cyst:
- Sx?
- associated with either _______ or _______
- Persistent corpus luteum cyst may cause local pain or tenderness
- **amenorrhea or delayed menstruation and can mimic clinical picture of ectopic
Corpus luteum cyst:
-complications?
torsion of ovary, rupture and bleed may cause severe pain and patient will present with peritoneal signs and acute abdomen
Corpus luteum cyst:
-S/Sx?
- Localized pain, tenderness
- Amenorrhea or delayed menstruation
Corpus luteum cyst:
-Tx?
- Watch and Wait, usually regress in 1-2 months
- OCPs have been recommended but questionable benefit
- *Laparoscopy or laparotomy is usually required to control hemorrhage or to perform detorsion of ovary
Polycystic ovarian syndrome aka ________ syndrome
**STEIN LEVENTHAL SYNDROME
Polycystic ovarian syndrome:
-characterized by ?
-Persistent anovulation and hyperandrogenism
-Oligomenorrhea/amenorrhea
Hirsutism
Obesity
Enlarged polycystic ovaries
infertility
-5-10% prevalence with variance among races/ethnicities
Polycystic ovarian syndrome: Clinical features
- ___% of Pts are Hirsute
- ____% of Pts are obese
- 50%
- 30-75%
*A presumptive diagnosis of PCOS can be made based on history and ____
PE
PCOS dx can be made if at least 2 of the following conditions are diagnosed: (list)
- Oligomenorrhea or amenorrhea
- Hyperandrogenism
- **Polycystic ovaries on US
PCOS:
-Labs: 4 things**
- elevated serum androgen levels–> Testosterone/DHEA-S
- Increased ratio of LH/FSH – 3:1
- Lipid abnormalities
- Insulin Resistance – HbA1c
PCOS:
Anovulation is identified in women with (4 things)
- Persistent high concentration of LH
- Low concentration of FSH
- Low day 21 progesterone level
- Sonographic follicular monitoring
PCOS: management
–Thought to be related to Hypothalamic pituitary dysfunction and insulin resistance
SO………….
- For all women with PCOS
- For women seeking pregnancy
- For women not seeking pregnancy
Tx of PCOS:
-Lifestyle changes:
–Weight loss – (2-7%)–> Improves ovulatory function,
Makes contraception easier and pregnancy safer,
and Lowers risk of diabetes
- Contraceptives - OCPs
- Metformin
- Infertility Treatments: **Clomiphene CITRATE (Clomid)= an ovulation stimulant
- Hirsutism Treatments
List Ex’s of hirsutism tx’s
Shaving/Laser, Spironolactone – Do not give to women wanting to get pregnant because can cause abnormal genitalia development in males
Treatment:
As patients with PCOS are chronically anovulatory, the endometrium is stimulated by estrogen alone. Endometrial hyperplasia and _____ are more frequent in patients with PCOS.
carcinoma
PCOS:
If endometrial hyperplasia occurs, can be treated with ______
**progesterone – Refer to GYN
- Repeat u/s
- **Mandatory endometrial biopsy to ensure no malignancy develops
A 26 year old woman who has not had any pregnancies comes to your office with a CC of being too hairy. She reports that her menses started at age 13 and have always been irregular. Her cycles are every 2-6 mo. She has acne and sees a dermatologist. She is otherwise healthy. Surgery – appendectomy at age 8
Vitals: Ht 5’5” Wt 180 BP: 100/60,
PE: sparse hair around nipples, chin and upper lip. No galactorrhea, thyromegaly or temporal balding.
Pelvic exam: no evidence of clitoromegaly, NTTP, no uterine or adnexal enlargement.
Which of the following likely explains her problem?
Adrenal tumor
Polycystic ovarian syndrome
Late onset congenital adrenal hyperplasia
Sertoli-Leydig cell tumor of ovary
Polycystic ovarian syndrome
Pheochromocytoma high bp, low potassium=
adrenal tumor
Ovarian Cancer Statistics:
- Early stage:
- Late stage:
- majority of women present w early or late stage disease?
-ovarian cancer presents with vague symptoms
VS
-Late stage disease presents with abdominal pain, bloating, early satiety, and or urinary urgency/frequency
-Majority–> late stage disease (deadliest GYN Cancer
Ovarian Cancer Statistics:
-Risk increases with age, mean age of diagnosis is mid ___
-Lifetime risk of ovarian cancer in general population is ___%
- 50’s
- 1.7%
Ovarian CA:
- causes?
- majority of adnexal cancers arise from:
- ____ is shown to be protective
- Hereditary causes of ovarian cancer
- arise from: the surface epithelial cells of the ovary
-**Oral contraceptive pills shown to be protective
Ovarian Cancer Risk Factors (list)
-Age of menses early or late onset menopause
Genetic factors:
- BRCA1 and BRCA2 tumor gene
- Family History of ovarian cancer puts you at risk
- Obesity
- Nulliparity
- Personal hx of breast, endometrial, or colon cancer
-Smoking
Ovarian Cancer: Clinical Features
- None
- Abdominal distention
- Ascites
- Pain
- Early satiety
- Urinary or GI symptoms
- Vaginal bleeding
- Estrogenic/androgenic Sx
- Complication can have rupture or torsion
Pt with Ovarian CA:
- Pelvic Exam will reveal ______
**solid, fixed, irregular, adnexal mass
Ovarian CA:
-Screening test of choice?
No good screening test, patients often present with advanced disease
Ovarian Cancer: Dx
-Labs:
- **CA-125 (but normal CA-125 level DOES NOT exclude Ovarian CA dx)
- Pregnancy test
- CBC (check for anemia)
- **AFP and LDH may be markers for malignant germ cell tumor
Ovarian CA: imaging?
- pelvic US: _____
- other imaging tests?
-**Pelvic US – solid mass, nodular or papillary, septations, and ascites,
Doppler can show increased blood flow to mass
- CT or MRI
- Chest x-ray for mets
- Screening mammogram
Ovarian CA:
Tx?
Surgical removal of tumor
Ovarian CA: prognostic factors (list 6)
- Stage
- Grade
- Histologic Type
- Size
- Age
- Residual Tumor
Staging of Ovarian Cancer (I-IV) Describe
I. Tumor limited to one or both ovaries
II. Tumor involves one or both ovaries w/ pelvic extension
III. Tumor involves one or both ovaries with confirmed peritoneal metastasis outside pelvis and/or regional lymph node metastasis
IV. Distant metastasis (excludes peritoneal cavity)
Ovarian CA:
-Divided into Epithelial ovarian cancers: (3 kinds)
- Surface epithelium stroma
- Sex cord stroma
- Germ cells
Epithelial ovarian Cancers (EOC) ____% of all malignant ovarian tumors
**80%
Epithelial Ovarian CA:
Describe the classic theory
Classic theory comes from repair to the ovarian epithelium during normal ovulation with subsequent genetic alterations and malignant transformation
Epithelial Ovarian CA:
-Describe the Secondary theory
high serum concentration of gonadotropins lead to epithelial proliferation and subsequent transformation
Epithelial Ovarian CA:
-describe the third theory
based on molecular findings is that these cancers are derived from the fallopian tube and endometrium
What is the BEST characterized marker for ovarian CA?
**CA-125= a glycoprotein
CA-125:
–seen in what other malignancies ?
- Cut off is somewhat arbitrary
- Seen in other malignancy such as pancreas, colon, breast, fallopian and endometrial
- Useful adjunct in postmenopausal
- **Normal CA-125 does not exclude a diagnosis of cancer
______ is a protein whose gene is overexpressed in a patient with serous and endometrioid ovarian cancers
**Human epididymis protein: (HE4)
KNOW!
Adolescents with adnexal mass should have which labs tested?**
**AFP, LDH and hCG given the greater likelihood of a malignant germ cell tumor
_____ Tumors account for majority of the epithelial ovarian cancers:
*Serous
Serous tumors:
- Develop from?
- May grow how large?
- These tumors/cysts develop from ovarian tissue and may be filled with a watery liquid or a mucous material
- May grow large enough to fill abdominal cavity, but usually smaller than mucinous tumor
Serous tumors:
-account for ___% of ALL epithelial ovarian neoplasms
-Ages 20-30 usually ______
vs
-perimenopausal and postmenopausal– more likely to be _______
- **75-85%
- Low grade neoplasms
-**cancer
Mucinous Ovarian Tumor:
-often they are ___ in origin and metastasize to ____
- GI (appendix)
- MET to ovary**
Mucinous Ovarian Tumor:
- Filled with ______
- Size: ?
- malignant or benign?
opaque, thick, mucoid material
- LARGEST tumors
- 75-85% are benign, favorable prognosis
Mucinous Ovarian Tumor:
- demographic?
- ___% are bilateral
- Most between 30-50 yo
- 8-10% are bilateral
Endometrioid tumors contain glandular material with a ______ ______ pattern resembling endometrial glands
**histological glandular pattern
Endometrioid tumors:
are termed “_______ cysts”
**chocolate
Endometrioid tumors can be seen in association with _____
-benign or malignant?
- *endometriosis
- Benign “tumor like” condition rather than a true neoplasm
Epithelial Tumors of the Ovary:
-Other tumors (list Ex’s)
- Clear cell tumors
- Transitional cell tumors (Brenner Tumor)
Epithelial Tumors of the Ovary::
tx?
**Surgical removal and forward to pathology
SEX CORD-STROMAL TUMORS:are rare about ___% of ovarian cancers, that secrete ____ ______ such as estrogen
1-2%
-sex steroids
Granulosa cell accounts for ___% of Sex cord-stromal tumors
-Granulosa cell tumors produce ______
70%**
-estrogen
Granulosa cell tumor:
2 types=
- juvenile
- adult
-*May present in juvenile as precocious puberty due to estrogen
Sex cord-stromal tumors:
Thecoma
- filled with:
- prroduces:
- Sx?
- have presented w/:
- Filled with lipid containing cells
- Produces Estrogen
- Sx: postmenopausal bleeding
- adenocarcinoma of endometrium from estrogen
Sex cord-stromal tumors: Thecoma -Size: -bilateral or unilateral? -malignant?
Size: **non-palpable to >20cm
- Rarely bilateral
- Rarely malignant
Sex cord-stromal tumors:
Thecoma
tx?
ranges depending on age from hysterectomy with bilateral salpingo-oophorectomy to ovarian cystectomy
Sex cord-stromal tumors:
Sertoli-Leydig Tumor
- Sx?
- Secretes: ?
- hirsutism, virilzation, menstrual irregularities, clitoromegaly
- Excess testosterone secreted by tumor
Sex cord-stromal tumors:
Sertoli-Leydig Tumor
-How common?
- Rare tumor that occurs in teens/young women
- -Hilus Cell Tumor is a Subset of Leydig cell tumor
- Originate from ovarian hilum
- Rarely attains a palpable size
Germ Cell tumors: Teratoma (dermoid cyst)
- ____% of all benign ovarian tumors
- Describe this tumor
-40-50%
=**Well differentiated tissue from 3 germ cell layers, including hair and teeth
Germ Cell tumors: Teratoma (dermoid cyst)
- demographic?
- Sx?
- Dx image of choice=
- Reproductive age women
- Usually asymptomatic
- *Ultrasound very accurate
Struma Ovarii= subset of monodermal teratoma
- It’s composed of _____
- accounts for __% of teratomas
- __% will produce Sx of thyroidtoxicosis
- almost entirely thyroid tissue
- 3%
- 5%
Other Gynecological Tumors: ie Fibroma -Produces hormones? -Demographic? Size?
- Do NOT produce hormones
- close to menopausal age
- Size: incidental finding to >20cm
Fibroma:
- nodules?
- Found as part of _____ syndrome**
- *Multinodular
- Found as part of Meig’s syndrome
Meig’s Syndrome:
Triad of Sx=
triad of benign ovarian tumor, ascites, and pleural effusion
Ovarian torsion may occur 2/2 _____
-pain?
enlarged ovary by a mass (cyst)
-**Causes Severe abdominal pain
Ovarian torsion:
- S/Sx=
- dx?
Acute severe abdominal or pelvic pain, usually localized to one side
Nausea/Vomiting
dx: good History, PE and imaging–>**Ultrasound with Doppler is imaging of choice
Ovarian torsion:
managment/treatment?
**Surgical Emergency*
admit them!!!
Complications of ovarian cancer are due to:
- metastases esp to abdomen
- Increased risk of venous thrombosis
Benign lesions of the fallopian tubes are routinely _______
-Size?
asymptomatic
- Rarely large enough to be palpable
- ->Exception is paratubal or paraovarian cyst
- Dx is incidental finding during imaging or during surgery
Hydatid cysts of Morgagni= ____ tumor found on ________ end of ovary
- cystic
- fimbriated end
Serous tumors are often paratubal OR _______
*paraovarian especially in the broad ligament, low malignancy potential
Adenomatoid Tumors:
- how common?
- Found where?
**MC benign tumor found in the fallopian tube
Hydrosalpinx=
Distally blocked fallopian tube filled with fluid
-*Blocked tube may become distended giving it a “sausage appearance”
Hematosalpinx=
fallopian tube filled with blood
**Pyosalpinx=
fallopian tube filled with pus
Hydrosalpinx:
-Sx:
Causes?
Sx can vary – asymptomatic, pelvic pain, or abdominal pain, common cause of infertility
-Causes may be recent injury, PID, endometriosis, abdominal surgery, ruptured appendicitis
Hydrosalpinx:
-imaging?
May be seen by Ultrasound, hysterosalpingogram, laparoscopy
Pelvic Inflammatory Disease (PID)= an infection of ______
-usually _______ etiology, common complication of ___
*female reproductive organs
- **polymicrobial, complication of G/C
- usually from ascending infection
PID:
often diagnosed clinically based on _____
**presence of Cervical Motion Tenderness or uterine/adnexal tenderness
PID May result in scarring and ______
infertility
PID: Sx
- Pain in lower abdomen or pelvis
- Fever
- Vaginal discharge
- Pain and/or bleeding with intercourse
- Nausea and/or vomiting
- Pelvic pressure or back pain
- Adnexal tenderness
- **Cervical motion tenderness
“chandelier sign” =
**PID
=severe pain elicited during pelvic examination of patients with pelvic inflammatory disease, in which the patient responds by reaching upward toward the ceiling for relief
PID: how to make the dx
dx can be made clinically and empiric treatment started in sexually active young women and other women at risk for STiS if they have pelvic or lower abd pain and no cause for illness other than PID can be identified with 1 or more of the following minimum criteria present on pelvic exam:
- Cervical motion tenderness
- Uterine tenderness
- Adnexal tenderness
PID dx:
- labs?
- imaging?
Wet prep may show abundant white cells CBC may show leukocytosis ESR and CRP may be elevated Swabs/URINE may be positive for G/C All tests may also be normal Transvaginal US or MRI may show thickening or fluid filled tubes Diagnostic laparoscopy
PID Complications:
-If diagnosed/treated early, complications can be ____
-List complications
- prevented
- Formation of scar tissue both outside and inside the fallopian tubes that can lead to tubal blockage
- Ectopic pregnancy
- Infertility
- Long-term pelvic/abdominal pain
- Peritonitis/bacteremia
- Intestinal Obstruction due to adhesion
PID: tx
-Ceftriaxone 250mg IM x 1 dose Plus
Doxycycline 100mg BID x 14 days with or without
Metronidazole 500 mg BID x 14 days
-May need to be hospitalized for IV antibiotics
–Cefotetan 2 g IV every 12 hours Plus
Doxycycline 100mg IV every 12 hours
