Disorders of the ovary Flashcards
Pathophys of polycystic ovary syndrome
Disordered LH production creates hyperinsulinaemia..
Increased adrenal and ovarian androgen production and lower SHBG production.
Disruption of folliculogenesis and raised serum androgens.
Clinical features of PCOS
Signs of hyperadrongenism - acne, hirsutism.
Irregular or absent menses.
Obesity (sign of insulin resistance).
Acanthosis nigricans (dry rough, dark skin).
Sleep apnoea.
Alopecia.
Mood abnormalities.
Criteria for PCOS diagnosis
Rotterdam Diagnostic Criteria.
2 out of 3 of:
oligo or a-menorrhoea
Polycystic ovaries on USS (>12 peripheral follicles or ovarian volume >10ml in one ovary)
Biochemical or clinical Signs of hyperadrogenism (hirsutism, acne, alopecia, raised testosterone)
Investigations for PCOS
Total testosteron (normal or middle high)
Sex hormone-binding globulin -SHBG (normal or low)
Calculate free androgen index
Lh and FSH
TSH
Prolactin
USS of ovaries (<12 follicles in at least one ovary or <10ml ovarian volume)
OGTT and fasting BM
Exclude other causes of irregular menses.
Management of PCOS
Lifestyle advice - loose weight, improve diet and regular exercise.
Symptomatic control.
Regular menses = COCP, IUS, metformin.
Hyperadrogenism: acne = COCP. Hirsutism = wax, laser, COCP.
Subfertility = weight loss, Clomiphene.
Complications of PCOS
Diabetes mellitus. Endometrial cancer. CVD. Infertility. Pregnancy complications e.g. gestational diabetes, pre-eclampsia. Psychological disorders. Obstructive sleep apnoea.
Meig’s syndrome
Benign ovarian tumour Ascites Pleural effusion. mostly in females over 40yrs. Rx = drainage of ascites and effusion + surgical removal of tumour.
Chocolate cyst
endometriomas - filled with old blood
Functional cyst
Arise from follicle or corpus luteum. Normal and small if <5cm. Resolve over menstrual cycles.
Chronic symptoms of a benign cyst
Asymptomatic Chronic dull achey pain. Dyspareunia Irregular PV bleeding Abdominal swelling or mass
Acute symptoms of benign cysts
Acute pain - bleeding/rupture, torsion of cyst.
Ovarian torsion or cyst rupture
Torsion = Sever lower abdo pain and vomiting.
Pain improves over 24hrs as ovary necrotises and dies.
Rupture = similar pain, may not improve and signs of haemorrhagic shock
Concerning features of a mass on a TVUS
Multilocular Large papillary cyst wall projections Solid areas Metastases Ascites Bilateral lesions
Management of cyst
Acute: if stable TVUS If unstable laparoscopy. If cyst >5cm laparoscopic ovarian cystectomy. If post-menopausal monitor CA125 closely.
Pelvic inflammatory disease possible areas
Endometritis Salpingitis Oophoritis Tubo-ovarian abscess Pelvic peritonitis Parametritis
Causes of PID
STI - Chlamydia, gonorrhoeae.
Risk factors for PID
Young age Early first sexual intercourse Multiple sexual partners STI history in female or partner Recent interruption in cervical barrier: TOP, insertion of IUD or IUS, IVF, hysterosalpingpgraphy.
Complications of PID
Infertility
Ectopic
Chronic pelvic pain
Fitz-Hugh Curtis syndrome
Fitz-Hugh Curtis syndrome
Right upper quadrant pain + Peri-hepitits
Clinical features of PID
Bilateral lower abod pain Deep dyspareunia Intermenstrual PV bleeding Post-coital bleeding Menorrhagia Purulent PV discharge. Examination - bilateral tenderness at adnexal and abdo, cervical excitation. Can have fever
Investigations for PID
STI screen
High vaginal swab
ESR and CRP raised (non-specific)
Pregnancy test
Management of PID
Antibiotics = 1xIM Ceftriaxone, oral doxycycline and metronidazole for 14days. Analgesia = paracetamol.
Red flag symptoms with chronic pelvic pain
Bleeding PR New bowel symptoms over age of 50 New pain after menopause Pelvic mass Suicidal ideation Excessive weight loss Irregular PV bleeding over 40yrs Postcoital bleeding.
Chronic pelvic pain definition
Intermittent or constant pain in the pelvis of a female for at least 6 months. It does not occur exclusively with menstruation, intercourse or potential pregnancy.
Pelvic pain with variation during cycle, dysmenorrhoea and dyspareunia
Endometriosis or adenomyosis
Dragging pelvic pain, dyspareunia, bladder or rectal problems
Prolapse
Other causes of chronic pelvic pain
Adhesions. IBS and interstitial cystitis Nerve entrapment PID Mittelschmerz pain
Causes of post-coital bleeding
CERVICAL SQUAMOUS CELL CARCINOMA
Cervical polyp
Cervical ectropion
STI
Differentials for acute pelvic pain
Ovarian torsion Cyst rupture Appendicitis Ectropic pregnancy Incomplete miscarriage
Rokitansky’s protuberance on histopathology
Teratoma/dermoid cyst. Arise from germ cells
