Gynecology - Ovarian cysts, tumors, PCOS Flashcards
What is the most common ovarian mass?
Ovarian cysts (75% of ovarian masses)
What are the three types of ovarian cysts?
Follicular cyst
Corpus luteum cyst
Theca lutein cyst
What are the types of primary ovarian neoplasms?
- Ovarian epithelial tumors
- Ovarian germ cell tumors
- Sex cord/stromal tumors
What is the pathophys. behind follicular cyst?
Failure of the follicle to rupture at the culmination of the follicular stage (day 14) of the menstrual cycle. Fluid then collects in the follicular antrum and expands. Size may vary from 3-8cm. Clasically asymptomatic.
What is the pathophys. behind corpus luteum cyst?
Failure of involution of the corpus luteum at the end of the luteal phase (day 28). Surrounding vessels bleed into the persistent corpus luteum. May bleed into peritoneum; delayed menstruation, dull LQ pain.
What is the pathophys. behind Theca lutein cyst?
Bilateral cysts caused by excessive hCG stimulation of the theca interna layer. There will often be multiple. Associated with ovarian hyeperstimulation, anything that increases hCG (GTD, multiple gestation), DM, PCOS
Risk factors for functional ovarian cyst?
- Smoking
- Progestin-only contraceptives
- Tamoxifen use
- Hx of previous cyst
! COC reduce the risk of functional ovarian cysts !
Most common symptomatic presentation of ovarian cysts?
Dull, vague lower abdominal pain.
Cx:
Ovarian torsion: sharp, unilateral pain of sudden onset in lower abdomen/pelvis. Often accompanied by N/V + fever.
Ovarian cyst rupture: Sharp, unilateral pain of sudden onset in lower abdomen/pelvis. Often accompanied by peritoneal signs, distension.
When is ovarian mass a red sign?
If it presents in a post-menopausal woman.
Best diagnostic test to determine a functional ovarian cyst?
Sonography (TAS or TVS).
Benign mass vs malignant mass:
Benign: Size: < 8cm Consistency: cystic Solid components: none Septations: none or single Doppler: negative Laterality: unilateral Assoc. fx: calcifications
Malignant: Size > 8cm Consistency: solid/mixed Solid components: nodular, papillary Septations: Multiocular, thich Doppler: positive Laterality: bilateral Assoc. fx: asictes, peritonealmets, LAN
When is laporascopic evaluation needed in ovarian cysts?
- if the cyst is > 7 cm
2. The patient is taking combined OCs.
What measures do you do in an asymptomatic cyst?
Can be managed expectantly; no immediate intervention is needed. Follow-up sonography should be performed at 6-8weeks.
When do you refer a pelvic mass for further workup in premenopausal women (< 50y)?
- Ascites
- Any evidence of abdominal or distant metastases
- Elevated CA-125 level
- OVA1 score > 5.0
When do you refer a pelvic mass for further workup in postmenopausal women (>50y)?
- Ascites
- Any evidence of abdominal or distant metastases
- Nodular or fixed mass
- Elevated Ca-125 level (>200)
- OVA1 Score > 4.4
Women with which familian gene is at higher risk for ovarian cancer?
Women with BRCA-mutation
Which types of Ovarian Cancer is the most common?
Ovarian epithelial tumors
Ovarian epithelial tumors - pathophysiology
Derived from the ovarian surface epithelium. Slow growing and usually advanced at diagnosis. Makes up 65-70% of ovarian tumors, but 90% of total ovarian cancers.
Germ cell tumors - pathophysiology
Derived from cells destined to become eggs. Most common cause of ovarian neoplasm and cancer in females under the age of 20. Rapid growing and usually stage 1 at diagnosis. Less than 5%.
Sex cord/stromal tumors - pathophysiology
Derived form hormone-producing cells or cells that make up the interstitium of the ovary. Age of onset is variable. Sex cord tumors produce hormones and hence may lead to symptoms not seen in the other tumors. Less than 5%.
Ovarian cancers - tumor markers
Epithelial - Ca-125 Dysgerminoma - LDH Endodermal sinus tumor - AFP Choriocarcinoma - hCG Embryonal carcinoma - AFP + hCG
Symptoms of ovarian neoplasms/cancers:
Usually asymptomatic until advanced. Vague, lower abdominal pain, abdominal distention, bloating, early satiety/other GI complaints, pelvic pressure.
What is a “typical” physical finding you can see in ovarian cancer?
“Sister Mary Joseph Nodule” (metastasis to the umbilicus)
What is the “Meig’s syndrome”?
Triad of ovarian tumor, ascites and R hydrothorax. (resolves after resection of the tumor)
Ovarian staging
Sjekk nett
Treating ovarian cancer
Women with stage IC epithelial ovarian cancer or greater must recieve chemo.
- Regular examination including pelvic exam every 3 months for 2 years, then every 4-6 months for 3 years, then every year.
- Ca-125 should be checked every visit
- CT if any suspicion of recurrence.
What is the mainstay of chemotherapy in epithelial ovarian cancer?
Carboplatin and paclitaxel
What is the most common endocrine disorder of reproductive age women?
PCOS.
Pathophysiology - PCOS
Etiology unknown, hormonal disturbances;
- Gonadotropins: Disturbed GnRH pulsatility leads to abnormal LH, FSH levels. Clasically LH:FSH > 2:1
- Insulin resistance
- Androgens: Both insulin and LH stimulate androgen production by the ovarian theca cell. Estrone increases due to peripheral conversion.
- SHBG: Women with PCOS have lower SHBG levels.
What does the disturbed LH, FSH levels lead to? In PCOS
Anovulation/hypoovulation
What does the increased androgens lead to? In PCOS
Hirsutism, acne, male pattern balding, dyslipidemia
What does the increased estrone lead to? In PCOS
Abnormal menstruation
What does the insulin resistance lead to? in PCOS
Acanthosis nigricans
DM2
What does the low adiponectin levels lead to? In PCOS
Obesity
What is the “Rotterdam criteria” for PCOS? (at least 2/3)
- Oligo- or anovulation
- Hyperandrogenism
- Polycystic ovaries identified sonographically
How do you manage PCOS?
Women with mild PCOS may be managed with observation alone.
COC are the cornerstone of medical management for PCOS.
- Helps reduce androgens by suppressing GnRH release
- Progestin component of COC reduces endometrial proliferation
Step 1: Induce withdrawal bleeeding;
- MPA 10mg PO for 10d
- Micronized progesterone 200mg PO for 10d
Step 2: Introduce oral contraceptives:
- Ethinylestradiol/drospirenone
- Ethinylestradiol/norgestimate
- Ethinylestradiol/desogestrel
How do you treat hirsutism?
- Eflornithine topical
- Spironolactone
- Surgical removal
General medical complications due to PCOS?
- Dyslipidemia (70%)
- Cardiovascular disease
- Endometrial neoplasia
- Obstructive sleep apnea
Obstetric complications due to PCOS?
- Infertility - due to anovulation
- Early miscarriage
- Gestational hypertension
- Gestational diabetes
- Preterm birth
- Perinatal mortality
The menstrual cycle
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