Gynae: Ovarian pathology (torsion, cysts)

Question 1

what is ovarian torsion?

Answer 1

• a condition where the ovary twists in relation to the surrounding connective tissue, fallopian tube and blood supply (known as the adnexa)

Question 2

what usually causes ovarian torsion?

Answer 2

• ovarian mass larger than 5cm ie cyst or tumour (more likely with benign tumour)
• more likely to occur during pregnancy
• in normal ovaries in younger girls before menarche when girls have longer infundibulopelvic ligaments that can twist more easily

Question 3

why is ovarian torsion an emergency?

Answer 3

twisting of the adnexa and blood supply to ovary leads to ischemia.

if torsion persists necrosis will occur and the ovary will die

Question 4

how does ovarian torsion present?

Answer 4

• sudden onset unilateral pelvic pain
  
  • it is constant and gets worse
  • associated with nausea and vomiting
• may not always be severe and may be milder and more prolonged
• pain that comes and goes may indicate the ovary twisting and untwisting intermittently

Question 5

how is ovarian torsion diagnosed?

Answer 5

pelvic ultrasound - whirlpool sign (free fluid in the pelvis and oedema of the ovary

(transvaginal ultrasound is preferred but abdominal is fine where this is not possible)

doppler may show lack of blood

definitive diagnosis = laparoscopic surgery

Question 6

how is an ovarian torsion managed?

Answer 6

laparoscopic surgery to:

untwist the ovary and fix it in place

or

remove the affected ovary

(decision made based on visual inspection in surgery)

Question 7

what are the complications of ovarian torsion? think removal and if not removed quickly

Answer 7

• loss of function of the ovary
  
  • if this is the only functioning ovary then loss of fertility and menopause
• necrotic ovary not removed may become infected, develop an abscess and lead to sepsis
• may rupture and cause peritonitis and adhesions

Question 8

what is an ovarian cyst?

Answer 8

fluid filled sac in the ovary

Question 9

ovarian cysts in pre and post menopausal women significance?

Answer 9

pre = fluctuating hormones of the menstrual cycle very common and most are benign

post = more concerning for malignancy and need to be investigated

Question 10

patients with multiple cysts on their ovaries cannot be diagnosed with PCOS even if they have the string of pearls appearance unless….

Answer 10

they have other features of PCOS (require at least 2)

• anovulation
• hyperandrogenism
• polycystic ovaries on ultrasound

Question 11

how do ovarian cysts present?

Answer 11

often asymptomatic and found accidentally on pelvic ultrasound scan

can be

• pelvic pain
• bloating
• fullness in the abdomen
• palpable mass
• may present with acute pain if there is torsion, hemorrhage or rupture

Question 12

what are the 2 types of functional cyst?

Answer 12

follicular cyst

corpus luteum cyst

Question 13

what is a follicular cyst and how do they appear on ultrasound?

Answer 13

• represent the developing follicle - when they fail to rupture and release the egg they can persist
• they are the most common and are harmless and tend to disappear after a few menstrual cycles
• they have thin walls and no internal structures so do not appear sinister on ultrasound

Question 14

what are corpus luteum cysts?

Answer 14

occur when the corpus luteum fails to break down and instead fills with fluids causing pelvic discomfort, pain or delayed menstruation

often seen in early pregnancy

Question 15

what is a serous cystadenoma?

Answer 15

benign tumor of the epithelial cells

Question 16

what is a mucinous cystadenoma?

Answer 16

benign tumor of the epithelial cells which can become huge and take up a lot of space in the pelvis and abdomen

Question 17

what is an endometrioma?

Answer 17

lumps of endometrial tissue within the ovary, occurring in patients with endometriosis. they can be painful and interrupt ovulation

Question 18

what are dermoid cysts/germ cell tumours?

Answer 18

benign ovarian tumours

teratomas meaning they come from germ cells and may contain various tissue types such as skin, teeth, hair, bone

Question 19

what are sex cord-stromal tumours?

Answer 19

rare tumours that can be benign or malignant

arise from stroma (connective tissue) or sex cord (embryonic structures associated with follicles)

several types including sertoli-leydig tumours and granulosa cell tumours

Question 20

investigating ovarian cysts - what do you need to look for in history and examination that could suggest malignancy? (not risk factors)

Answer 20

• abdominal bloating
• reduce appetite
• early satiety
• weight loss
• urinary symptoms
• pain
• ascites
• lymphadenopathy

Question 21

investigating ovarian cysts - what are some risk factors for ovarian malignancy?

Answer 21

• age
• postmenopausal
• increased number of ovulations
• obesity
• HRT
• smoking
• breastfeeding (protective)
• family history of BRCA1 and BRCA2 genes

Question 22

state 4 things that will reduce the number of ovulations a woman and therefore reduce her risk of ovarian cancer

Answer 22

• late onset of periods
• early menopause
• pregnancies
• use of COCP

Question 23

premenopausal women with a simple ovarian cyst less than 5cm on ultrasound scan do not need further investigation

Question 24

management for possible ovarian cancer (complex cysts or raised CA125)

Answer 24

2ww referral to gynaecological oncology specialist

Question 25

management of possible dermoid cyst

Answer 25

referral to gynaecologist for further investigation and consider for surgery

Question 26

simple ovarian cysts in premenopausal women can be managed based on their size…

Answer 26

less than 5cm = will almost always resolve within 3 cycles (follow up scan not required)

5cm-7cm = required routine referral to gynaecology and yearly ultrasound monitoring

>7cm = consider MRI scan or surgical evaluation as they can be difficult to characterise with ultrasound

Question 27

Cysts in postmenopausal women generally require correlation with the CA125 result and referral to a gynaecologist. When there is a raised CA125, this should be a two-week wait suspected cancer referral. Simple cysts under 5cm with a normal CA125 may be monitored with an ultrasound every 4 – 6 months.

Persistent or enlarging cysts may require surgical intervention (usually with laparoscopy). Surgery may involve removing the cyst (ovarian cystectomy), possibly along with the affected ovary (oophorectomy).

Question 28

what are some complications of ovarian cysts?

Answer 28

• torsion
• hemorrhage into cyst
• rupture with bleeding into the peritoneum

Question 29

what is Meig’s syndrome?

Answer 29

triad of ovarian fibroma, pleural effusion, ascites

typically occurring in older women - removal of the tumour results in complete resolution of the effusion and ascites

Question 30

what is a simple ovarian cyst?

Answer 30

one which contains fluid only

Question 31

what is a complex ovarian cyst?

Answer 31

anything that is not simple

can be irregular and can contain solid material, blood or have septations or vascularity