Ovarian cysts (inc. PCOS)

Question 1

What is PCOS? What are the 4 main symptoms of it?

Answer 1

Polycystic Ovarian Syndrome

Symptoms (PCOS):

Periods (irregular)
Clinical hyperandrogenism (hirsuitism, acne)
Obesity and insulin resistance
Subfertility

Question 2

What are the criteria to diagnose PCOS?

Answer 2

Need at least 2/3 of:

Menstrual irregularity
Hyperandrogenism (elevated serum total and free testosterone or DHEAS
Polycystic appearance of ovaries on U/S

Question 3

Name 3 potential pathophysiological causes of PCOS

Answer 3

Androgen excess (adrenal or ovarian)
Abnormal LH secretion
Abnormal ovarian steroid synthesis

Question 4

What is the definition of an ovarian cyst?

Answer 4

A fluid-filled, epithelial-lined sac in ovarian tissue

Question 5

Name 5 causes/classifications of ovarian cysts and give an example of a cyst in each category

Answer 5

Physiological - exaggerated response to normal physiological process (follicular, endometrioid, corpus luteum cysts)

Infectious - abscess, or cystic collection of cellular debris (tubo-ovarian abscess)

Benign neoplastic - excessive growth of ovarian cells without dysplasia (fibroma, cystadenomas, mature teratoma/dermoid cyst)

Malignant neoplastic - excess growth with dysplasia (cystadenocarcinomas, endometrioid carcinoma, immature teratoma)

Metastatic (often from endometrial, colonic or gastric cancers)

Question 6

Name 5 risk factors for developing an ovarian cyst

Answer 6

Pre-menopausal
Early menarche
First trimester of pregnancy
Infertility/PCOS
Increased gonadotrophins (either endogenous - like beta-HCG release in pregnancy, or exogenous - like in infertility treatment)
Tamoxifen
Endometriosis

Question 7

Name 3 symptoms/signs of an ovarian cyst

Answer 7

Pelvic pain
Bloating
Palpable mass on bimanual examination

Question 8

Name 2 standard Ix for an ovarian cyst

Answer 8

Transvaginal U/S +/- Doppler studies

Serum Ca-125

Question 9

What is CA-125 primarily used for? Name 5 other cases where it may be elevated

Answer 9

Diagnosis of ovarian Ca. Can also be raised in women with gall bladder/pancreatic cancer, uterine fibroids, endometriosis, PID, adenomyosis, pregnancy and menstruation

Question 10

A woman presents with acute-onset pelvic pain, signs of shock and vital sign abnormalities. Name 3 Ddx

Answer 10

Twisted ovarian cyst/torsion
Appendicitis
Ectopic pregnancy
PID

Question 11

Name 3 Ix if suspicious of an ovarian torsion, and expected results

Answer 11

Transvaginal U/S - look for ovarian enlargement
Doppler U/S - look for reduced venous flow
Laparoscopy (ideally

Question 12

What are you most worried about if you find an incidental ovarian cyst in a post-menopausal women? Name 3 other symptoms associated with this condition. Name 3 further Ix to do.

Answer 12

Ovarian Ca. Other symptoms - abdo/pelvic pain, bloating, increased abdominal girth, early satiety, increased urinary frequency/urgency

Further Ix - Doppler U/S, CA125, laparotomy and oopherectomy for histopathology

Question 13

Name 4 Ddx for an adnexal mass on U/S

Answer 13

Benign ovarian cyst (endometrioma, cystic teratoma)
Malignant ovarian cyst
PID
Hydrosalpinx

Question 14

What is the difference between CA-125 interpretation in a premenopausal and postmenopausal woman?

Answer 14

CA-125 needs to be much higher in a pre-menopausal woman before you start worrying about ovarian Ca (>200 U/mL vs > 35 U/mL) - lower prevalence of ovarian Ca + more false positives in younger women

Question 15

What 3 factors does the Risk of Malignancy Index take into account for in determining ovarian Ca risk?

Answer 15

U/S results
Menopausal status
CA-125 level

Question 16

Name 3 features on U/S suggestive of a malignant ovarian cyst

Answer 16

Multi-locular
Solid areas
Metastases
Ascites
Bilateral lesions
Tumour volume
Wall thickness/papillary structure

Question 17

What are the two options for management of an ovarian cyst?

Answer 17

Leave it in (but monitor with follow-up every 3-4 months for U/S +/- CA125 if post-menopausal), or…
Cut it out!

Question 18

Name 3 complications of an ovarian cyst

Answer 18

Ruptured cyst and bleeding/peritonitis
Ovarian torsion
Dyspareunia
Disseminated cancer

Question 19

Name 2 risk factors for PCOS

Answer 19

FHx
Premature adrenarche (early onset pubic/axillary hair, sweat gland development)

Question 20

Name 4 Ddx for PCOS, and an Ix to diagnose each condition

Answer 20

21-hydroxylase deficiency (blocks cortisol and aldosterone synthesis = shunts cortisol metabolism to make androgens) - look for elevated 17-hydroxyprogesterone
Hypo/hyperthyroidism (both lead to reduced ovulation/irregular menstruation) - TSH levels
Hyperprolactinaemia - prolactin levels
Cushing’s syndrome (raises cortisol as well as androgen levels) - 24 hr urinary free cortisol
Androgen-secreting neoplasm (steroid-producing tumours of adrenals or ovary) - do imaging
Depression - … whatever you do to diagnose depression

Question 21

Name interventions for the three main symptoms of PCOS (subfertility, hyperandrogenism, irregular periods) - at least 2 for each symptom.

Answer 21

Subfertility:

Weight loss, then metformin, then clomifene, then gondaotrophins, then IVF

Hyperandrogenism:

OCP (works by inhibiting GnRH = inhibits ovarian androgen secretion, and increase SHBG = more binding of testosterone), antiandrogens (spironolactone, cyproterone, 5-alpha reductase inhibitors - finasteride), metformin, long-acting gonadotrophins

Irregular periods:

Weight loss, metformin (both induce ovulation), or OCP (progesterone exposure = sloughing of endometrium)

Question 22

What is a risk of oligomenorrhoea in PCOS?

Answer 22

In PCOS, women have chronic oestrogen without progesterone exposure = endometrial hyperplasia and cancer