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Yr4: Obstetrics & Gynaecology > Gynae: Ovarian Disorders > Flashcards

Gynae: Ovarian Disorders Flashcards

1
Q

What is PCOS?

A

Polycystic ovarian syndrome

Condition in which there are metabolic & reproductive problems in women. Characteristic features: multiple ovarian cysts, infertility, oligomenorrhoea, hyperandrogenism & insulin resistance

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2
Q

When does PCOS tend to present (age wise)?

A

Puberty

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3
Q

State some risk factors for PCOS

A
  • FH
  • Diabetes
  • Obesity
  • Irregular menstruation
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4
Q

Describe the pathophysiology of PCOS

A

Insulin resistance is a crucial part of PCOS. When someone is resistant to insulin, their pancreas has to produce more insulin to get a response from the cells of the body. Insulin promotes the release of androgens from the ovaries and adrenal glands. Therefore, higher levels of insulin result in higher levels of androgens (such as testosterone). Insulin also suppresses sex hormone-binding globulin (SHBG) production by the liver. SHBG normally binds to androgens and suppresses their function. Reduced SHBG further promotes hyperandrogenism in women with PCOS.

The high insulin levels contribute to halting the development of the follicles in the ovaries, leading to anovulation and multiple partially developed follicles (seen as polycystic ovaries on the scan).

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5
Q

Describe typical presentation of PCOS

A
  • Oligomenorrhoea or amenorrhoea
  • Infertility
  • Obesity (~70%)
  • Hirsutism
  • Acne
  • Male pattern hair loss
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6
Q

State some differential diagnoses for hirsutism

A
  • Medications (corticosteroids, testosterone, anabolic steroids, phenytoin, ciclosporin)
  • Cushing’s syndrome
  • Congenital adrenal hyperplasia
  • Ovarian or adrenal tumours secreting androgens
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7
Q

Alongside features listed in typical presentation FC, what other problems may women with PCOS experience?

A
  • Insulin resistance and diabetes
  • Acanthosis nigricans
  • Cardiovascular disease
  • Hypercholesterolaemia
  • Endometrial hyperplasia and cancer
  • Obstructive sleep apnoea
  • Depression and anxiety
  • Sexual problems
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8
Q

What investigations are done in women with suspected PCOS?

A

Bedside

  • Oral glucose tolerance test

Blood tests

  • Testosterone
  • SHBG
  • LH
  • FSH
  • TSH
  • Prolactin
  • Progesterone??? CHECK

Imaging

  • Transvaginal pelvic ultrasound (NOTE: not reliable in adolescents for diagnosis of PCOS)
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9
Q

What blood results would suggest PCOS?

A
  • Raised LH
  • Raised LH:FSH ratio
  • Raised testosterone
  • SHBG: low
  • Testosterone: normal or mildly elevated
  • Progesterone: low throughout menstrual cycle
  • Prolactin: may be mildly raised
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10
Q

When is it best to measure LH & FSH?

A

Days 1-3 of menstrual bleed

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11
Q

What findings on ultrasound would suggest PCOS?

A

“String of pearls appearance”

  • 12 or more developing follicles in one ovary
  • Or ovarian volume more than 10cm3
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12
Q

Remind yourself of the findings in OGTT that would indicate diabetes

A

An OGTT is performed in the morning prior to having breakfast. It involves taking a baseline fasting plasma glucose, giving a 75g glucose drink and then measuring plasma glucose 2 hours later. It tests the ability of the body to cope with a carbohydrate meal. The results are:

  • Impaired glucose tolerance – plasma glucose at 2 hours of 7.8 – 11.1 mmol/l
  • Diabetes – plasma glucose at 2 hours above 11.1 mmol/l
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13
Q

What criteria used to diagnose PCOS? Describe this criteria

A

Rotterdam Criteria

At least 2 of the three features:

  • Oligoovulation or anovulation (presenting with irregular or absent periods)
  • Hyperandrogenism (characterised by hirsutism & acne)
  • Polycystic ovaries on ultrasound (or ovarian volume >10cm3)
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14
Q

Management of PCOS can be split into 5 categories; state these

A
  • General management
  • Managing hirsutism
  • Managing acne
  • Managing infertility
  • Managing risk endometrial cancer/oligomenorrhoea or amenorrhoea
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15
Q

Discuss the general management of PCOS

A

Must reduce risk associated with obesity, T2DM, hypercholesterolaemia, CVD:

  • Weight loss
  • Exercise
  • Smoking cessation
  • Antihypertensives
  • Statins (QRISK >10%)
  • Orlistat (lipase inhibitor to help weight loss in women with BMI >30)
  • Assess for & treat any other complications:
    • Endometrial hyperplasia
    • Depression & anxiety
    • OSA
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16
Q

Discuss the management of hirsutism in PCOS

A
  • Weight loss can improve symptoms
  • Hair removal (waxing, shaving, plucking)- many women already tried
  • Co-cyprindiol (Dianette): COCP licensed for treatment of hirsutism & acne as has anti-androgen effect
  • Topical eflornithine for facial hirsutism (takes 6-8 weeks to work and hirsutism often return when stop using)
  • Other medications that have anti-androgen effects:
    • Spironolactone (mineralocorticoid receptor antagonist)
    • Finasteride (5-alpha reductase inhibitor)
    • Flutamide (non-steroidal anti-androgen)
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17
Q

Discuss the management of acne in PCOS

A
  • COCP Co-cyprindiol (Dianette) is first line
  • Other acne management:
    • Topical benzoyl peroxide
    • Topical macrolide antibiotics
    • Topical azelaic acid
    • Oral tetracycline abx
    • Isotretinoin
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18
Q

State one ADR of Co-cyprindiol (Dianette)

A

Significantly increased risk of VTE hence often stopped after 3 months

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19
Q

Discuss the management of subfertility in PCOS

A
  • Weight loss
  • Metformin (+/- clomifene) *NICE recommend metformin for women with BMI >25
  • Clomifene
  • Ovarian drilling (laparoscopic surgery in which put multiple holes in ovaries using diathermy or laser)
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20
Q

Discuss the management of risk of endometrial cancer/oligomenorrhea/amenorrhoea in PCOS

A

In Oligoovulation or anovulation, there is unopposed oestrogen hence can lead to endometrial hyperplasia which has risk of becoming malignant.

  • Options to induce withdrawal bleed (at least 3 times per year):
    • COCP
    • Cyclical progesterone (E.g. medroxyprogesterone acetate 10mg once a day for 14 days)
  • Mirena coil for continuous protection
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21
Q

Explain why women with PCOS at risk of endometrial cancer

A

Under normal circumstances, the corpus luteum releases progesterone after ovulation. Women with PCOS do not ovulate (or ovulate infrequently), and therefore do not produce sufficient progesterone. They continue to produce oestrogen and do not experience regular menstruation. Consequently, the endometrial lining continues to proliferate under the influence of oestrogen, without regular shedding during menstruation. This is similar to giving unopposed oestrogen in women on hormone replacement therapy. It results in endometrial hyperplasia and a significant risk of endometrial cancer.

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22
Q

How should we investigate women with extended gaps (>3 months) between periods or abnormal bleeding?

A
  • Pelvic ultrasound to assess endometrial thickness
  • Give cyclical progestogens to induce period prior to ultrasound and if thickness is >10mm need to refer for biopsy to exclude endometrial hyperplasia or cancer
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23
Q

What is ovarian torsion?

A

Ovarian torsion (or adnexal torsion) is a twisting of the ovary and/or fallopian tube on its vascular and ligamentous supports, blocking adequate blood flow to the ovary.

24
Q

What usually causes ovarian torsion?

A
  • Usually due to ovarian mass larger then 5cm (e.g. cyst or tumour- more likely with benign tumours)
  • Can occur in girls with normal ovaries before menarche if have longer infundibulopelvic ligaments
25
Q

Explain why ovarian torsion is an emergency

A

Torsion may compromise blood supply to ovaries → ischaemia → necrosis → loss of function of ovary

26
Q

Describe typical presentation of ovarian torsion

A
  • Sudden onset severe unilateral pelvic pain (constant, gets progressively worse. HOWEVER, may not always be severe could b milder and have a prolonged course. May be hx of pain that comes and goes as ovary twists & untwists)
  • Associated nausea & vomiting
  • Localised tenderness
  • May be palpable mass
27
Q

How is ovarian torsion diagnosed?

A
  • Initial investigation of choice: transvaginal pelvic ultrasound (or transabdominal if transvaginal not possible)
  • Definitive diagnosis made with laparoscopic surgery
28
Q

What might you see on pelvic ultrasound of pt with ovarian torsion?

A
  • “Whirlpool sign”
  • Oedema of ovary
  • Free fluid in pelvis
  • Doppler may show lack of blood flow
29
Q

Discuss the management of ovarian torsion

A

Emergency admission to gynaecology for urgent investigation & management. Will have laparoscopic surgery to either:

  • Un-twist ovary & fix in place (detorsion)
  • Remove affected ovary if become necrotic (oophorectomy)

… decision often made during surgery after visual inspection of ovary

**NOTE: laparotomy may be required if large ovarian mass or malignancy suspected

30
Q

State some potential complications of ovarian torsion

A
  • Loss of function of ovary (other ovary can usually compensate however if only one of ovaries is functioning and that one is affected → infertility & menopause)
  • If necrotic ovary not removed → infected → abscess → may then rupture to cause peritonitis and adhesions or cause sepsis
31
Q

Functional ovarian cysts related to fluctuating hormones of menstrual cycle are very common in premenopausal women; true or false?

A

True

32
Q

Vast majority of ovarian cysts in pre-menopausal women are….?

A

Benign

Cysts in post-menopausal women are more concerning & need further investigation

33
Q

Most ovarian cysts are asymptomatic and found incidentally on pelvic ultrasound; however, state some symptoms a pt may present with

A
  • Pelvic pain
  • Bloating
  • Fullness in abdo
  • Palpable pelvic mass
34
Q

What is the most common type of ovarian cyst?

A

Follicular cysts

35
Q

There are two types of functional cysts; state these

A
  • Follicular cysts
  • Corpus luteum cysts
36
Q

For follicular cysts, discuss:

  • What they are/how formed
  • Prognosis
  • Appearance on ultrasound
A
  • Form when follicles fail to rupture and release an egg
  • Harmless, tend to disappear after few menstrual cycles
  • Thin walls & no internal structures
37
Q

For corpus luteum cysts, discuss:

  • What they are/how they are formed
  • Symptoms
  • When seen
A
  • Corpus luteum fails to break down and fills with fluid
  • Pelvic discomfort/pain, delayed menstruation
  • Often seen in early pregnancy
38
Q

State some other types of ovarian cysts (other than functional cysts)

A
  • Serous cystadenoma: benign tumour of epithelial cells
  • Mucinous cystadenoma: benign tumour of epithelial cells that can become very large
  • Endometriomas/”chocolate cysts”: lumps of endometrial tissue in ovary occurring in pts with endometriosis
  • Dermoid cysts/germ cell tumours: benign ovarian tumours arising from germ cells which can contain various tissue types e.g. skin, hair, teeth, bone
  • Sex cord stromal tumours: rare, benign or malignant. Arise from stroma (connective tissue) or sex cords (embryonic structures associated with follicles). Different types: Sertoli-Leydig and granulosa cell. Fibroma is most common stromal tumour
39
Q

State some important questions to ask in someone with suspected or confirmed ovarian cysts

A
40
Q

What investigations would you do if you suspect ovarian cyst(s)?

A
  • Initial investigation: ultrasound (transvaginal or transadominal??? CHECK)

Further investigations varies:

  • Pre-menopausal women with simple ovarian cyst <5cm= no further investigation (or re-scan in 6 weeks)
  • CA125
  • If <40yrs with complex ovarian mass need to assess following as they are tumour markers of germ cell tumours:
    • LDH
    • a-FP
    • HCG
41
Q

CA125 is not very specific; state some potential non-malignant causes of raised Ca-125

A
  • Endometriosis
  • Fibroids
  • Adenomyosis
  • Pelvic infection
  • Liver disease
  • Pregnancy
42
Q

What tool is used to assess the risk of an ovarian mass being malignant/risk stratify in those with suspected ovarian cancer?

A

Risk of malignancy index (RMI)

Takes into account:

  • Menopausal status
  • Ultrasound findings
  • CA125 level
43
Q

Management of ovarian cysts depends on suspected pathology; discuss the management of ovarian cysts in:

  • Pre-menopausal women with simple cysts
  • Post-menopausal women
  • Dermoid cysts
  • Persistent or enlarging cysts
A

Pre-menopausal with simple cysts

Managed based on size:

  • <5cm: no follow up scan required
  • 5-7cm: routine referral gynaecology & yrly ultrasound
  • >7cm: consider MRI or laparoscopy

Post-menopausal

  • Need to do CA-125
  • If raised CA-125 2WW referral gynaecology
  • If simple cyst <5cm with normal CA-125 monitor with ultrasound every 4-6 months

Dermoid cysts

  • Referral to gynae for further investigation & consideration surgery

Persistent or enlarging cysts

  • May require surgical intervention
    • Ovarian cystectomy
    • Oophorectomy
44
Q

State some potential complications of ovarian cysts

A
  • Torsion
  • Haemorrhage into cyst
  • Rupture (& bleeding into peritoneum → peritonitis)
45
Q

What is Meig’s syndrome?

A
  • Ovarian fibroma
  • Pleural effusion
  • Ascites

*Commonly in older women. Removal of tumour resolves effusion& ascites.

46
Q

What is premature ovarian insufficiency?

A

Menopause before age of 40yrs

Example of a hypergonadotropic hypogonadism (underactivity of ovaries results in lack of negative feedback on pituitary hence gonadrophin production is increased)

47
Q

State some potential causes of premature ovarian insufficiency- highlight most common

A
  • Idiopathic (>50%)
  • Iatrogenic (chemotherapy, radiotherapy, surgery e.g. bilateral oophorectomy)
  • Autoimmune (coeliac, T1DM, thyroid disease, adrenal insufficiency)
  • Genetic (FH, Turner’s syndrome)
  • Infections (mumps, measles, CMV)
48
Q

Describe typical presentation of premature ovarian insufficiency

A
  • Oligomenorrhoea
  • Secondary amenorrhoea
  • Infertility
  • Symptoms low oestrogen:
    • Hot flushes
    • Night sweats
    • Vaginal dryness
    • Low mood
49
Q

What investigations would you consider for a pt with suspected premature ovarian insufficiency?

A
  • Main test= FSH

Note: additional testing of serum luteinizing hormone (LH), oestradiol, prolactin, testosterone, and thyroid-stimulating hormone (TSH) levels may be helpful for the diagnostic work-up.

50
Q

It is difficult to interpret hormone blood results in women taking hormonal contraception; true or false?

A

True

51
Q

What would you expect the following to be in premature ovarian insufficiency:

  • Oestradiol
  • FSH
  • LH
A
  • Oestradiol: low
  • FSH: high
  • LH: high

NICE: premature ovarian insufficiency can be diagnosed in women <40yrs with typical menopausal symptoms AND raised FSH. FSH must be persistently raised (>30IU/L) on two consecutive samples more than 4 weeks apart.

52
Q

Discuss the management of premature ovarian insufficiency

A
  • HRT until at least age at which women typically go through menopause (~51yrs). Options:
    • Traditional HRT (see menopause FC for more info)
    • COCP
  • Contraception (small risk of pregnancy if ovarian activity spontaneously resumes hence if on HRT also need contraception)
53
Q

Discuss whether there is an increased risk of breast cancer in those taking HRT, compared with normal population, before aged 50yrs

A

HRT before 50yrs not considered to increase risk of breast cancer

54
Q

There may be an increased risk of VTE in women <50yrs taking HRT; how can this risk be reduced?

A

Transdermal HRT e.g. patches

55
Q

Women with premature ovarian insufficiency are at risk of certain conditions due to low oestrogen; state some examples

A
  • Cardiovascular disease
  • Stroke
  • Osteoporosis
  • Cognitive impairment
  • Dementia
  • Parkinsonism
56
Q

Discuss the management of ruptured ovarian cyst in pt who is acutely unwell

A
  • NBM in case of surgery
  • IV fluids
  • IV analgesia
  • IV abx
  • Surgical exploration with laparoscopy or laparotomy

Yr4: Obstetrics & Gynaecology (24 decks)

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