Lecture 17 - Ovarian Disorders Flashcards
Ovarian cysts
derived from a neoplastic process –growth of tissues –that occurs within the ovary
most arise in the ovary of fallopian tube (para-ovarian cyst)
rarely cancerous in young populations
What lab do you need to run for any women of childbearing age that presents with pelvic pain or irregular bleeding?
BhCG
risk of ectopic pregnancy
What is the clinical presentation of people with ovarian cysts?
most are asymptomatic
may also cause: pelvic pain -dull/sharp -constant/intermettent pelvic pressure/fullness painful intercourse bloating torsion
adnexal fullness, tenderness
What are the two compartments of ovary?
cortex (outer portion)
-follicles/eggs here
medulla (inner potion)
Simple vs complex cyst
simple:
- filled with serous/watery fluid
- composed of granulosa cells (SAME cells as follicles)
- Thin walled
- regress spontaneously
- almost always benign
- can reach 5-7cm, typically not much larger
Complex:
- may be fluid filled: blood, mucous, etc
- solid component
- internal debris
- thick walled
- sepations
- papilla
- typically benign, but should have lower threshold of suspicion (>5cm, >45yo)
Functional cysts
arise from normal ovarian function (less common in menopausal women)
resolve spontaneously
Chocolate cysts
endometrioma causing a cyst
“ground glass” appearance on US
What causes a cyst in the ovaries?
Endometrioma
Theca Lutein Cysts
Medullary and germ cell tumors
Endometrioma
cause behind cyst formation
“chocolate cysts”
complex
ground glass appearance on US
ectopic growth of endometrial tissue –more pain on periods
will likely have elevated CA 125
typically does NOT resolve spontaneously
Tx: expectant management (watch and wait)
laparoscopy removal
OCP
Lupron in the form of depo
Elevated CA 125
doesn’t always have to mean cancer (tumor marker for ovarian cancer)
can be endometrioma
Theca Lutein Cysts
RARE luteinized follicular cysts 96% bilateral seen in pregnancy, molar pregnancy, multiple gestation, ovulation induction, GnRH analogue use, DM common denominator HCG
typically resolved after source of HCG is removed
Medullary and germ cell tumors
of the ovaries
neoplasia related to gene expression changes that lead to mitosis
these cysts do NOT typically resolve with time and should be monitored or resected
mature cystic teratoma (AKA dermoid cyst)
- germ cell tumor –> ectodermal, mesoderm, endodermal
- represents 70% of ovarian neoplasms age 10-30 yo
Immature teratoma
= cancer
What is the treatment for mature cystic teratoma?
watch and wait (aka dermoid cyst)
Cystadenoma
serous and mucinous (typically unilateral)
thin walled –> can initially look similar to simple cyst
What are the different ways to manage a benign cyst?
symptomatic treatment
- most cysts resolve spontaneoulsy (within 1-2 menstrual cycles)
NSAIDs, heat
Hormonal treatment
OCP for simple cyst and endometriomas –> prevent new cysts from forming (controversial as to whether or not they will “shrink” the existing cyst)
Surgical management
cyst aspiration
can be accompanied by methotrexate injection (reduce fluid production and recurrence)
laparoscopy –> cysts typically >4-5 cm and causing refractory pain
What are concerning findings of ovarian cysts?
high suspicion of malignancy:
- solid component
- irregularly thick septations
- blood flow in solid component (internal blood flow)
- ascites
- peritoneal masses, enlarged lymph notes, matted bowel
obtain pelvic MRI and CA-125
70% of malignant ovarian tumors present how?
multiocular with solid components
CA-125
blood test used to indicate malignancy (biomarker)
expressed in 80% of epithelial cell tumors
does NOT indicate severity of disease
more concerning in postmenopausal women
slight elevations in premenopausal might be nothing, unless its elevated by like 200 –thats a red flag
What is the number one gyn malignancy?
endometrial cancer
What is the second most common gyn malignancy?
ovarian cancer
most common cause of cancer death
likely because late stage at diagnosis
What is the average age at dx of ovarian cancer?
60 y/o
Are there any reliable screening tests for ovarian cancer?
no
Ovarian cancer is a common location for which metastisized cancers?
endometrial
breast
colon
What causes an increased risk of ovarian cancer?
family hx genetic predisposition -lynch syndrome -BRCA 1/2 delayed childbearing/nulliparous early menarche late menopause endometriosis obesity E2 replacement for > 5 years
What puts you at decreased risk for ovarian cancer?
breastfeeding >18 months multiparity late menarche early menopause OCP use (5+ year use reduces risk by 40-50%) Tubal ligation/hysterectomy
What are signs and sxs of ovarian cancer?
abdominal fullness backpain constipation diarrhea early satiety fatigue nausea pelvic pain pelvic mass inguinal lymphadenopathy weight loss
What is the most common type of ovarian cancer?
Epithelial cell –85-95%
most common >50yo
Stroma cell
5-8% of ovarian cancer
2 types:
Granulosa-theca
Sertoli-Leydig –common in adolescence –seen masculinizing d/t elevated testosterone
Which type of ovarian cancers are more common in pediatric populations?
germ cell tumors
3-5% of all ovarian tumors
Ovarian torsion
one of the most common gyn emergencies
impede blood supply
sx: SEVERE pain (sharp, stabbing/clociky, radiation)
N/V
low grade fever
Risk factors:
childbearing age –> ovarian cysts (generally >5cm), neoplasms, pregnancy
RIGHT side MC affected
What are the sxs of ovarian torsion?
SEVERE pain (sharp, stabbing/clociky, radiation)
N/V
low grade fever
What are risk factors of ovarian torsion?
childbearing age –> ovarian cysts (generally >5cm), neoplasms, pregnancy
Which ovary is most likely to be involved in torsion?
RIGHT
What is the work up for ovarian torsion?
HCG, CBC, CMP, TAUS/TVUS with doppler
“String of pearls”
“string of pears” = multiple small peripheral follicles seen in PCOS
What is the treatment for ovarian torsion?
de-torsion and ovarian conservation, possibly ovarian cystectomy, possible oopherectomy
rare that you’re able to treat or restore
PCOS
polycystic ovarian syndrome
aka Stein-Leventhal Sydnrome
6.5-8% of women
MC cause of infertility
ligelong dx
common comorbidities: obesity CV disease DM2 dyslipidemia OSA endometrial carcinoma depression/anxiety
What is the most common cause of infertility?
PCOS
Do women with PCOS have high incidences of ovarian cysts?
NO
these women do NOT ovulate so they usually do not have ovarian cysts
What do you see on US with a pt who has PCOS?
not cysts surprisingly
you see an increased number of antral follicles
Rotterdam Criteria
dx criteria for PCOS
at least 2 needed for dx:
Oligo- and/or anovulation (d/t low progesterone)
Clincial and/or biochemical signs of hyperandrogenism
polycystic ovaries - “string of pearls”
What is the treatment for PCOS?
goal: help prevent endometrial cancer by putting them on progesterone to shed the lining
Global progesterone keeps their lining thin
Endometrial protection: OCPs, IUD, metformin
Acne:
spironolactone
Hirsuitism:
low androgen OCP, spironolactone
Infertility:
weight loss, metformin, Clomid, ovarian drilling
Insulins resistance and/or hyperandrogenism:
weight loss, metformin
A 29y/o G1P1 with regular, 28 day cycles present for scan on cycle day 13. The sonography sends you the images. What hormone levels should you check?
Estrogen and LH
since 13th day is right around the time for ovulation
A 19yo G0 presents with dull midline/right sided cramping x 1 week. Her menses started 3 days ago and bleeding is light, as usual. She hasn’t tried any OTC analgesics because they usually don’t alleviate her symptoms. She is in a monogamous relationship with 1 partner and occasionally uses barrier contraception, but takes the Plan B morning-after pill the same day if needed. She’s currently not taking any medication and has NKDA. What should be your next step?
Pelvic exam and swab for STI and Urine HCG
What is the most common type of ovarian cancer?
epithelial cell
