Gynaecology: PCOS, Ovarian Cysts & Ovarian Torsion Flashcards
1
Q
What is the most common endocrine disorder affecting women of reproductive age?
A
PCOS - affects 10% of women
2
Q
Pathophysiology of PCOS?
A
Excessive androgen production and multiple ovarian cysts.
3
Q
Main clinical features of PCOS?
A
- Anovulatory infertility
- Acne
- Hirsutism
- Irregular menstrual cycles
- Obesity
- Increased long term risks of cardiovascular events
- Increased risk of endometrial cancer
4
Q
Is PCOS inherited?
A
Yes but the genetic inheritance of PCOS is heterogeneous and complex.
Appears to be inherited in an autosomal dominant fashion.
5
Q
What is the leading environmental contributor in PCOS?
A
Post-natal obesity
6
Q
What 2 mechanisms can lead to excess androgen production in PCOS?
A
Due to one or both:
1) Excess LH (luteinising hormone) production
2) Hyperinsulinemia and insulin resistance
7
Q
How can hyperinsulinemia and insulin resistance lead to excess androgen production?
A
Excess insulin in the bloodstream promotes androgen production by the ovaries.
Hyperinsulinemia may stimulate the ovary to over-produce testosterone and prevent the follicles from growing normally to release eggs. This causes the ovaries to become polycystic.
8
Q
Most women with PCOS have “cysts” found on their ovaries. What are these cysts?
A
These are immature follicles which have had their ovulation phase arrested.
9
Q
Cause of cysts in PCOS?
A
This occurs due to an elevated baseline of LH and lack of LH surge (as in a normal menstrual cycle).
10
Q
Risk factors for PCOS?
A
Obesity
Diabetes mellitus
Family history of PCOS
Premature adrenarche (early onset of pubic hair)
11
Q
Define anovulation
A
Absence of ovulation
12
Q
Define oligoovulation
A
irregular, infrequent ovulation
13
Q
Define oligomenorrhoea
A
irregular, infrequent menstrual periods
14
Q
define hyperandrogenism
A
The effects of high levels of androgens
15
Q
Define hirsutism
A
The growth of thick dark hair, often in a male pattern, for example, male pattern facial hair
16
Q
What criteria is used for making a diagnosis of PCOS?
A
Rotterdam Criteria
17
Q
What is the Rotterdam Criteria?
A
A diagnosis requires at least two of the three key features:
1) Oligoovulation or anovulation, presenting with irregular or absent menstrual periods
2) Hyperandrogenism, characterised by hirsutism and acne
3) Polycystic ovaries on ultrasound (or ovarian volume of more than 10cm3)
It is important to remember that only having one of these three features does not meet the criteria for a diagnosis. As many as 20% of reproductive age women have multiple small cysts on their ovaries. Unless they also have anovulation or hyperandrogenism, they do not have polycystic ovarian syndrome.
18
Q
What triad is seen in PCOS?
A
1) Anovulation
2) Hyperandrogenism
3) Polycystic ovaries on US
19
Q
Clinical features of PCOS?
A
- Acne
- Hirsutism
- Infertility
- Hair loss & male pattern baldness
- Depression and other psychological disorders
- Menstrual cycle disturbance
- Obesity (about 70% of PCOS patients)
20
Q
Whjat is the most common symptom of PCOS?
A
Hirsutism
21
Q
Where is hirsutism most commonly in PCOS?
A
Face, chest, and back
22
Q
Other features and complications of PCOS:
A
- Insulin resistance and diabetes
- Acanthosis nigricans
- Cardiovascular disease
- Hypercholesterolaemia
- Endometrial hyperplasia and cancer
- Obstructive sleep apnoea
- Depression and anxiety
- Sexual problems
- Increased risk of metabolic syndrome ; HTN, obesity
23
Q
What is acanthosis nigricans? What is it associated with?
A
Thickened, rough skin, typically found in the axilla and on the elbows. It has a velvety texture. It occurs with insulin resistance.
24
Q
Differential diagnoses of hirutism?
A
- Medications, such as phenytoin, ciclosporin, corticosteroids, testosterone and anabolic steroids
- Ovarian or adrenal tumours that secrete androgens
- Cushing’s syndrome
- Congenital adrenal hyperplasia
25
How are insulin and androgens related?
When someone is resistant to insulin, their pancreas has to produce more insulin to get a response from the cells of the body.
1) 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).
2) 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.
26
How does insulin relate to anovulation in 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).
27
What can help with insulin resistance in PCOS?
Diet, exercise and weight loss
28
Differentials for PCOS?
1) Thyroid dysfunction --> particularly hypothyroidism can lead to hair loss and menstrual cycle irregularities. However, hirsutism is rare.
2) Congenital adrenal hyperplasia (21-hydroxylase deficiency) --> this causes cortisol deficiency and may also lead to androgen excess, leading to a clinical picture indistinguishable from that of PCOS.
3) Cushing’s syndrome --> excess cortisol production, leading to many features similar to PCOS (e.g. weight gain, acne, hypertension, insulin resistance).
4) Hyperprolactinaemia --> can lead to changes in the menstrual cycle. Galactorrhoea is usually present.
29
Bedside investigations in PCOS?
hCG --> rule out pregnancy
Capillary blood glucose --> insulin resistance and TD2 can be a sequela of PCOS
30
What blood tests should be done in PCOS?
- Baseline blood tests: FBC, U&E, CRP
- Testosterone
- Sex hormone-binding globulin (SHBG): normal to low in PCOS
- Testosterone to SHBG ratio: may be raised
- LH and FSH: LH if often raised, and a LH:FSH ratio >3 can suggest PCOS
- Oral glucose tolerance test: to assess insulin resistance
- Lipid screen: to assess cardiovascular risk (PCOS can cause dyslipidaemia)
31
How will testosterone be affected in PCOS?
Raised
32
How will LH to FSH ratio be affected in PCOS?
Raised (high LH compared with FSH)
33
How will LH be affected in PCOS?
Raised
34
How will insulin be affected in PCOS?
Raised
35
Most important imaging investigation in PCOS?
Pelvic ultrasound scan
36
What would a pelvis US typically show in PCOS?
Classically showing ≥12 follicles (“cysts”) on the ovaries and/or increased ovarian volume (>10cm3). The follciles may be arranged around the periphery of the ovary, giving a “string of pearls” appearance.
However, the syndrome can exist without polycystic ovaries.
37
Gold standard investigation for visualising the ovaries?
Transvaginal US
38
Diagnostic criteria for PCOS from pelvic US?
1) 12 or more developing follicles in one ovary
OR
2) Ovarian volume of more than 10cm3
39
Who is a pelvic US not reliable in for PCOS diagnosis?
Adolescents
40
What is the screening test of choice for diabetes in patients with PCOS?
2-hour 75g oral glucose tolerance test (OGTT).
41
When is an OGTT performed?
in the morning prior to having breakfast.
42
What is involved in an OGTT?
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.
43
What OGTT result implies an impaired fasting glucose?
Fasting glucose of 6.1 – 6.9 mmol/l (before the glucose drink)
44
What OGTT result implies an impaired glucose tolerance?
Plasma glucose at 2 hours of 7.8 – 11.1 mmol/l
45
What OGTT result implies diabetes?
plasma glucose at 2 hours above 11.1 mmol/l
46
General management of PCOS?
It is crucial to reduce the risks associated with obesity, type 2 diabetes, hypercholesterolaemia and cardiovascular disease:
- Weight loss
- Low glycaemic index, calorie-controlled diet
- Exercise
- Smoking cessation
- Antihypertensive medications where required
- Statins where indicated (QRISK >10%)
47
Specific management options for PCOS?
COCP --> role in restoring regular menstruation, reducing the risk of endometrial hyperplasia, and reducing the effects of hyperandrogenism (such as hirsutism and acne)
Specific anti-androgens e.g. cyproterone acetate or drospirenone
Eflornithine hydrochloride (Vaniqa cream) --> useful in reducing unwanted facial hair
Metformin --> used to reduce the insulin resistance associated with PCOS, and in turn, helps to promote regular menstruation and increases fertility
Orlistat --> a pancreatic lipase inhibitor which can be used in severe cases to assist with weight loss, should conservative measures fail
Management of depression & anxiety
48
What plays a significant role in the management of PCOS?
Weight loss
49
What drug may be used to help weight loss in women with a BMI above 30?
Orlistat
50
What class of drug is orlistat? Mechanism?
Lipase inhibitor --> stops the absorption of fat in the intestines.
51
Women with polycystic ovarian syndrome have several risk factors for endometrial cancer.
What are these?
- Insulin resistance
- Obesity
- Amenorrhoea
- Diabetes
52
Why can PCOS increase risik of endometrial cancer?
1) Women with PCOS do not ovulate (or ovulate infrequently),
2) Therefore do not produce sufficient progesterone due to no corpus luteum
3) They continue to produce oestrogen and do not experience regular menstruation.
4) Consequently, the endometrial lining continues to proliferate under the influence of oestrogen, without regular shedding during menstruation.
5) Endometrial hyperplasia and significant risk of endometrial cancer
53
What is the most common complication of PCOS?
Infertility (affects over 75% of women)
54
Investigations for potential endometrial cancer in women with PCOS?
Women with extended gaps between periods (more than three months) or abnormal bleeding need to be investigated with a pelvic ultrasound to assess the endometrial thickness.
Cyclical progestogens should be used to induce a period prior to the ultrasound scan.
If the endometrial thickness is more than 10mm, they need to be referred for a biopsy to exclude endometrial hyperplasia or cancer.
55
What endometrial thickness needs a referral to exclude endometrial hyperplasia or cancer in PCOS?
>10mm
56
Options for reducing the risk of endometrial hyperplasia and endometrial cancer in PCOS?
1) Mirena coil for continuous endometrial protection
2) Inducing a withdrawal bleed at least every 3 – 4 months with either:
a) Cyclical progestogens (e.g. medroxyprogesterone acetate 10mg once a day for 14 days)
b) Combined oral contraceptive pill
57
What is the initial step for improving fertility in PCOS?
Weight loss
58
Women with PCOS that become pregnant require screening for what?
Gestational diabetes
59
How is gestational diabetes screened for?
Screening involves an OGTT, performed before pregnancy and at 24 – 28 weeks gestation.
60
What is licensed for the treatment of hirsutism and acne in PCOS?
Co-cyprindiol (Dianette) --> a combined oral contraceptive pill
61
What are pros and cons of using COCP in PCOS?
Pros --> acne, hirsutism, contraceptive, regulates periods
Cons --> significantly inreased risk of VTE
62
How long is co-cyprindiol (Dianette) taken for in PCOS?
Only 3 months due to VTE risk
63
What can be used to treat facial hirsutism in PCOS?
Topical eflornithine
64
Standard treatments for acne?
- COCP
- Topical adapalene (a retinoid)
- Topical antibiotics (e.g. clindamycin 1% with benzoyl peroxide 5%)
- Topical azelaic acid 20%
- Oral tetracycline antibiotics (e.g. lymecycline)
65
What is a cyst?
A fluid filled sac
66
What is a functional ovarian cyst?
related to the fluctuating hormones of the menstrual cycle
67
Who are functional ovarian cysts common in?
Premenopausal women - the vast majority are benign
68
Who are ovarian cysts more worrying in?
Postmenopausal women - more concerning for malignancy and need further investigation.
69
Can a patient with multiple ovarian cysts or a “string of pearls” appearance to the ovaries be diagnosed with PCOS?
Only if they also have other features of the condition
70
What does a diagnosis of PCOS require?
A diagnosis of PCOS requires at least two of:
- Anovulation
- Hyperandrogenism
- Polycystic ovaries on ultrasound
71
Presentation of ovarian cysts?
Usually asymptomatic and found incidentally on pelvic US.
Occasionally can cause vague symptoms:
- Pelvic pain
- Bloating
- Fullness in the abdomen
- A palpable pelvic mass (particularly with very large cysts such as mucinous cystadenomas)
72
When can an ovarian cyst present with acute pelvic pain?
If there is ovarian torsion, haemorrhage or rupture of the cyst.
73
What are the 2 types of functional ovarian cysts?
1) Follicular cysts
2) Corpus luteum cysts
74
How does a follicular ovarian cyst develop?
When the developing follicle fails to rupture and release the egg, the cyst can persist.
75
What is the most common ovarian cyst?
Follicular ovarian cyst
76
Prognosis of a follicular ovarian cyst?
They are harmless and tend to disappear after a few menstrual cycles.
77
Appearance of a follicular ovarian cyst on US?
Typically they have thin walls and no internal structures, giving a reassuring appearance on the ultrasound.
78
How does a corpus luteum ovarian cyst form?
Occur when the corpus luteum fails to break down and instead fills with fluid.
79
Presentation of corpus luteum cyst?
They may cause pelvic discomfort, pain or delayed menstruation.
80
When are corpus luteum cysts typically seen?
Early pregnancy
81
Name some other types of ovarian cysts
1) Serous cystadenoma
2) Mucinous cystadenoma
3) Endometrioma
4) Dermoid cyst/germ cell tumour
5) Sex-cord stromal
82
What is a serous cystadenoma?
These are benign tumours of the epithelial cells.
83
What type of ovarian cyst can become huge, taking up lots of space in the pelvis and abdomen?
Mucinous cystadenoma
84
What is an endometrioma?
These are lumps of endometrial tissue within the ovary, occurring in patients with endometriosis. They can cause pain and disrupt ovulation.
85
What type of ovarian cyst is associated with ovarian torsion?
Dermoid cyst/germ cell tumour (teratoma)
86
Give 2 types of sex cord-stromal tumours?
1) Sertoli-Leydig cell tumours
2) Granulosa cells tumours
87
What must be established in an ovarian cyst?
Whether they are benign or malignant
88
Risk factors for ovarian malignancy?
Age
Postmenopause
Increased number of ovulations
Obesity
Hormone replacement therapy
Smoking
Breastfeeding (protective)
Family history and BRCA1 and BRCA2 genes
89
What symptoms may indicate a malignant ovarian cyst?
Abdominal bloating
Reduce appetite
Early satiety
Weight loss
Urinary symptoms
Pain
Ascites
Lymphadenopathy
90
Premenopausal women with a simple ovarian cyst less than what size do not need further investigations?
<5cm on US
91
What is the tumour marker for ovarian cancer?
Ca-125
92
What tumour markers are required for women under 40 with a complex ovarian mass?
For a possible germ cell tumour:
- Lactate dehydrogenase (LDH)
- Alpha-fetoprotein (α-FP)
- Human chorionic gonadotropin (HCG)
93
What 3 things does the RMI take into account?
1) Menopausal status
2) Ca-125
3) US findings
94
How are simple ovarian cysts managed?
Based on their size
95
How are <5cm ovarian cysts managd?
Will almost always resolve within three cycles. They do not require a follow-up scan.
96
How are 5-7cm ovarian cysts managed?
Require routine referral to gynaecology and yearly ultrasound monitoring.
97
How are >7 cm ovarian cysts managed?
Consider an MRI scan or surgical evaluation as they can be difficult to characterise with ultrasound.
98
How are cysts in postmenopausal women managed?
Need to get a Ca-125 level.
If raised --> 2 week wait referral
99
Complications of ovarian cysts?
Consider complications when patients present with acute onset pain.
- Torsion
- Haemorrhage into the cyst
- Rupture, with bleeding into the peritoneum
100
What is Meig's syndrome? What is the triad of symptoms?
A triad of:
1) Ovarian fibroma (a benign type of ovarian tumour)
2) Pleural effusion
3) Ascites
TIP: It is worth remembering Meig’s syndrome for your MCQ exams. Look out for the woman presenting with a pleural effusion and an ovarian mass.
101
Who does Meig's syndrome typically occur in?
Older women
102
Management of Meig's syndrome?
Removal of the tumour results in complete resolution of the effusion and ascites.
103
What is ovarian torsion?
Where the ovary twists in relation to the surrounding connective tissue, fallopian tube and blood supply (the adnexa).
104
What is most common cause of ovarian torsion?
Usually due to an ovarian mass larger than 5cm e.g. cyst or tumour
105
What size ovarian masses typically cause ovarian torsion?
>5cm
106
Is ovarian torsion more likely to occur with benign or malignant tumours?
Benign
107
When is ovarian torsion most likely to occur?
During pregnancy
108
When can ovarian torsion occur with NORMAL ovaries (i.e. no tumour)?
Why?
Before menarche
Girls have longer infundibulopelvic ligaments that can twist more easily.
109
Main complication of ovarian torsion?
Ischaemia --> necrosis
Therefore, ovarian torsion is an emergency, where a delay in treatment can have significant consequences.
110
What is the main presenting feature of ovarian torsion?
Sudden onset severe unilateral pelvic pain
111
Describe the pain in ovarian torsion
- Sudden onset
- Severe (however can sometimes take a milder and more prolonged course)
- Unilateral
- Constant and gets progressively worse
- Associated with N&V
N.B. Occasionally, the ovary can twist and untwist intermittently, causing pain that comes and goes.
112
Examination results in ovarian torsion?
On examination there will be localised tenderness.
There may be a palpable mass in the pelvis, although the absence of a mass does not exclude the diagnosis.
113
1st line imaging investigation in ovarian torsion?
Pelvic US (transvaginal is ideal, but transabdominal can be used where transvaginal is not possible)
114
What may be seen on a pelvic US in ovarian torsion?
- Whirlpool sign
- Free fluid in pelvis
- Oedema of ovary
Doppler studies may show a lack of blood flow.
115
Definitive diagnosis of ovarian torsion?
Laparoscopic surgery
116
What sign on US indicates ovarian torsion?
Whirpool sign
117
What are the 2 management options for ovarian torsion?
1) Untwist the ovary and fix it in place (detorsion)
2) Remove the affected ovary (oophorectomy)
The decision whether to save the ovary or remove it is made during the surgery, based on a visual inspection of the ovary.
118
Does removal of the ovary or loss of function of the ovary affect fertility?
Not typically - other ovary can compensate
119
What can happen if the ovary becomes necrotic during torsion?
Where a necrotic ovary is not removed, it may become infected, develop an abscess and lead to SEPSIS.
Additionally it may rupture, resulting in peritonitis and adhesions.
120
Why is pelvic US not reliable for PCOS diagnosis in adolescents?
Pelvic US should not be used for the diagnosis of PCOS in those with a gynaecological age of < 8 years (i.e. < 8 years post menarche) due to the high incidence of multi-follicular ovaries in this life stage.
121
