ICL 9.3: Benign Diseases of the Ovary Flashcards
30 years old G0 presents with lower abdominal pain. been around for 5-6 weeks. no abnormal discharge or lesions. regular periods. pain radiates to the left side and radiates down the leg. gets better with motrin but then comes back. sexually active but uses condoms. no recent STI tests.
diagnosis?
1.
what are the ligaments of the uterus and ovaries?
- suspensor ligament
- utero-ovarian ligament
- broad ligament
- round ligament
what is the adnexal mass?
anything next to the uterus in the region of fallopian tube and ovary
in pre-menarche and post-menopausal women you really shouldn’t feel anything because they don’t have high levels of estrogen and if you do feel something that’s probably a problem
what is a simple vs. complex ultrasound finding?
SIMPLE
- hypo-echoic
- thin-walled
COMPLEX
- hyperechoic/solid components
- thick walls
- septations
- excrescences
which cysts are functional cysts?
- follicular cyst
thin with minimal vasculature
- corpus luteal cyst
thicker with more vessels around it
can both develop into hemorragic cysts over time
how do you treat follicular cysts?
just monitor if there are no symptoms and the patient has no other symptoms; don’t even need to re-image
pain can occur if they are persistent, there’s torsion or rupture and then you could need possible surgical intervention
what are the complications associated with cysts?
- pain
- torsion
surgical emergency! causes ischemia so you can sometimes see lack of blood flow on US dopler; this going and coming of blood flow can cause waves of nausea
- rupture
what is a polycystic ovary?
multiple follicles in an ovary
usually anovulatory and obese patients and they have secondary amenorrhea
what are the diagnostic criteria for PCOS?
- oligo/amenorrhea
- biochemical signs or clinical symptoms of elevated testosterone (hirtuism)
- US showing 12+ follicles in each ovary measuring 2-9 mm in diameter and/or increased ovary volume of 10+ mm
you need 2/3 to have PCOS
how do you treat PCOS?
regulate their menstrual cycle!
if you’re not having normal menses you’re at increased risk for endometrial cancer – combined OCP or progesterone only OCP or hormonal IUD can be used to do this and make sure atypical cells don’t grow
estrogen/prosterone combination pill helps control testosterone levels and MAY decrease hirtuism
what is an ectopic pregnancy?
patient will present with positive pregnancy test, possible vaginal bleeding and pain an ectopic pregnancy should be in your differential! could also be fluid in the pelvis if the ectopic pregnancy has ruptured
it’s a pregnancy outside the uterus
common in the ampulla of the fallopian tube because that’s where fertilization occurs!
can also be in the ovary, C-section scar, cervix, isthmus of fallopian tube
“ring of fire” sign on US!!!!
what are the risks for ectopic pregnancy?
- PID
- age
- IUD
- endometriosis
- h/o ectopic pregnancy
- h/o abdominal surgery that caused scarring
how do you treat ectopic pregnancy?
- methotrexate
- surgical
salpingectomy (to preserve fertility) vs. salpingostomy
how does methotrexate treat ectopic pregnancy?
competitively inhibits dihydrofolate reductase which inhibits pyrimidine synthesis so you can’t make DNA
so it effects actively replicating cells and during early pregnancy there is A LOT of replication happening and methotrexate messes that up
on day 0 and then IM methotrexate is given based on body surface area – repeat β-hCG after day 4 and it should rise from tissue breakdown – then do again on day 7 and there should be a 15% decline in β-hCG levels and if you don’t see it then they need another dose of methotrexate – if there is a decline, you follow it weekly till β-hCG is 0
when would you use methotrexate vs. surgical intervention for ectopic pregnancy?
how far along are there? the most hCG the bigger the adenexal pathology so over 3.5 cm or more isn’t good to use methotrexate
if they’re unstable do surgery
you need patient compliance with methotrexate and they’ll have to be able to come in and get lab draws to check β-hCG levels
what are the 3 types of benign ovarian neoplasms?
- epithelial
serious, mutinous, endo metroid
- stromal
fibroma, thecoma
- germ cell
teratoma
what is a serious cystadenoma?
one of the most common epithelial benign neoplasms
usually bilateral
thin walls
what is a mutinous cystadenoma?
a type of epithelial benign ovarian neoplasm
usually multilobulated
HUGE
less often bilateral
what is a benign endometroid cyst?
you usually find these actually in the benign stages…..so the benign variant is rare
it’s associated with endometriosis and concurrent primary endometrial carcinoma
tumor appears cystic with solid areas
usually bilateral
what are the symptoms of adenectal masses?
CA-125 levels to rule out ovarian cancer
symptoms: vague bloating, urinary frequent/hesitancy, pelvic discomfort
what is a fibroma?
rare but the more common the sex cord stromal tumors
usually asymptomatic because the fibroma develops slowly
Meg syndrome: ovarian fibroma + pleural effusion + ascites –
what is Meg syndrome?
ovarian fibroma (sex cord stromal tumor) + pleural effusion + ascites
due to increased VEGF that causes capillary permeability
what is a thecoma?
bening ovarian stromal neoplasm that secretes estrogen so can cause early menses etc.
solid mass with someone who has abnormal uterine bleeding
post-menopausal women usually
what is a mature cystic teratoma?
aka dermoid that is a benign germ cell neoplasm
usually in 20-30 years old
contains all 3 germ cell layers and so you can see hair, teeth, etc.
what are other adnexal masses you should be aware of?
- endometrioma
- tubo-ovarian abscess
- hydrosalpinx
what is an endometrioma?
due to ectopic endometrial tissue that develops outside the uterus…eh go list 57 minutes
what is a tubo-ovarian abscess?
caused by an ascending infection involving fallopian tube and adjacent organs
lots of adhesions seen grossly
treat with antibiotics or admit if septic and start IV antibiotics; interventional radiology for draining if no improvement or surgery if necessary
what are the risk factors of tubo-ovarian abscess?
- STI
- tobacco
- multiple partners
what is a hydrosalpinx?
usually it’s PIV that causes scarring or clubbing of fibrae ends which causes fallopian tube to expand
usually asymptomatic but seen in infertile women
may cause embryos not to implant
