Module 3: Ovaries: General Info and Cysts and Surface Epithelial Tumors Flashcards
First before we talk about the various tumors of the ovaries lets first discuss the basic physiology of the female hormones. What is the role of LH and FSH?
LH: acts on theca cells —- androgen production
FSH: acts on granulosa cells — convert androgens —- estradiol (proliferative phase) — LH surge —- ovulation (secretory stage) — corpus luteum —- progesterone — degenerate follicles —- follicular cysts
What happens to the cell if you have a chronically high LH?
Multiple cysts lined by granulosa cells and hypertrophied theca interna cells
Now before discussion on the ovarian tumors lets first touch on the cysts diseases. The first is a Simple Cyst (physiological cyst, non-neoplastic cyst). What are some general features?
No dysplasia seen (hence its non-neoplastic) No chance of malignancy Women of reproductive age Unilateral Best investigation: Ultrasound Spontaneous resolution Asymptomatic
Now there are two types of Simple Cyst that are named according to the time of your menstrual cycle. First is the Follicular Cyst. what are some Features?
During the Estrogen (Follicular) Phase
- -before ovulation is called follicular phase in the ovary and proliferative phase in the uterus.
- -lined by cuboidal granulosa cells
- -Women that hasn’t been menstruating is going to be stuck in the estrogen phase so therefore this cyst predominates.
The second type of Simple Cyst is the luteal cyst. What are some features
During Progesterone (luteal) phase
–after ovulation you have luteal phase in the ovary and secretory phase in the uterus
–most common symptom is asymptomatic.
–Prego patients will have these types of cysts because they have high progesterone levels as well as hydatiform moles and gestational choriocarcinoma.
–Lipid laden cells called Theca cells
Seen when lots of betaHCg is being produced
What is the major complications for Simple (non-neoplastic) cysts?
More than 7cm increased risk of rupture and torsion and if on the right side then mimics acute appendicitis.
Moving on to the next female ovarian cysts are the Chocolate Cysts of the ovaries. What is the etiology?
Etiology: Endometrosis (repeated cyclical hemorrhage) — induces fibrosis, adhesions, and severe pain
What is the morphology seen for patients with chocolate cysts of the ovary?
Morphology: normal endometrial glands amidst stroma with hemorrhages (hemosiderin laden macrophages)
What is a complication of chocolate cysts of the Ovary?
May extend along pelvic ligaments and associated with infertility (Due to tubal scars)
–needs to be distinguished from corpus luteum cysts
Finally the last of the cysts of the ovaries is Polycystic Ovarian Disease (Stein-Leventhal Syndrome). Who present with this?
Black women of reproductive age that are obese
All due to increased estrogen levels
What is the pathogenesis for polycystic ovarian disease?
LH stimulates theca cells — Androgen Production —- converted to estrogen in the adipose tissue by aromatase — increased estrogen levels —- negative feedback on the anterior pituitary —- decreased FSH — no negative feedback on hypothalamus – Elevated GNRH — Stimulates LH production by anterior pituitary (Should stimulate FSH, but estrogen keeps it low) — LH stimulates theca cells – cycle continues
What levels are elevated and what levels are reduced in Polycystic Ovarian Disease?
Elevated: Estrogen, LH, GNRH, Androgen, Insulin and Glucose
Low: FSH and progesterone (Because you are not ovulating)(no neg feedback from progesterone to LH)
What is the presentation for patients that have polycystic ovarian disease?
Women of reproductive age
Obesity — peripheral insulin resistance – type II diabetes
No ovulation
*amenorrhea, infertility – due to persistently high LH (No LH spike)
Virilization
–Hirsutism (hair)
Slide 2 is a picture of the cysts. Explain the appearance of the cysts in polycystic ovarian disease
Multiple Cysts in BOTH ovaries:
–subcapsular or subcortical cysts
–Follicular cysts (patients arent ovulating)
Both ovaries are enlarged
–thickened (hypertrophied) stroma in both ovaries due to constant stimulation by LH
Necklace like appearance of the cysts
What are the best investigations for polycystic ovarian disease?
Most accurate: Hormone Profile
–LH to FSH ratio most accurate test 3:1
Can do ultrasound: necklace like appearance of the cysts with a hypertrophied stroma
Finally what are the complications for polycystic ovarian disease?
- Type II diabetes (metabolic syndrome)
- Infertility
- Hirsutism
- Fatty Liver and NASH (non alcoholic steatohepatitis) due to the obesity
- Endometrial hyperplasia — endometrial carcinoma
What treatments are used for polycystic ovarian disease?
- Chlormiphine: Induces ovulation (regularizes cycle)
2. Metformin for obesity and diabetes