Ovarian Disease

Question 1

Polycystic ovary syndrome (PCOS) is

Answer 1

complex condition of ovarian dysfunction thought to affect between 5-20% of women of reproductive age. The aetiology of PCOS is not fully understood. Both hyperinsulinaemia and high levels of luteinizing hormone are seen in PCOS and there appears to be some overlap with the metabolic syndrome.

Question 2

Polycystic ovary syndrome (PCOS) sx

Answer 2

subfertility and infertility
menstrual disturbances: oligomenorrhea and amenorrhoea
hirsutism, acne (due to hyperandrogenism)
obesity
acanthosis nigricans (due to insulin resistance)

Question 3

Polycystic ovary syndrome (PCOS) ix

Answer 3

pelvic ultrasound: multiple cysts on the ovaries
FSH, LH, prolactin, TSH, and testosterone are useful investigations

raised LH:FSH ratio is a ‘classical’ feature but is no longer thought to be useful in diagnosis.

Prolactin may be normal or mildly elevated.

Testosterone may be normal or mildly elevated - however, if markedly raised consider other causes

check for impaired glucose tolerance

Question 4

Polycystic ovarian syndrome: management - General

Answer 4

weight reduction if appropriate

if a women requires contraception then a combined oral contraceptive (COC) pill may help regulate her cycle and induce a monthly bleed

Question 5

Polycystic ovarian syndrome: management - Hirsutism and acne

Answer 5

a COC pill may be used help manage hirsutism. Possible options include a third generation COC which has fewer androgenic effects or co-cyprindiol which has an anti-androgen action. Both of these types of COC may carry an increased risk of venous thromboembolism
if doesn’t respond to COC then topical eflornithine may be tried
spironolactone, flutamide and finasteride may be used under specialist supervision

Question 6

Polycystic ovarian syndrome: management

Infertility

Answer 6

weight reduction if appropriate

metformin, clomifene or a combination should be used to stimulate ovulation

Metformin is not a first line treatment of choice in the management of PCOS
metformin is also used, either combined with clomifene or alone, particularly in patients who are obese
gonadotrophins

Question 7

There is a potential risk of multiple pregnancies with anti-oestrogen* therapies

Answer 7

true

Question 8

anti-oestrogen therapies work by?

Answer 8

work by occupying hypothalamic oestrogen receptors without activating them. This interferes with the binding of oestradiol and thus prevents negative feedback inhibition of FSH secretion

Question 9

Benign ovarian cysts are extremely common. What types?

Answer 9

physiological cysts, benign germ cell tumours, benign epithelial tumours and benign sex cord stromal tumours.

Question 10

Complex (i.e. multi-loculated) ovarian cysts should be biopsied to exclude malignancy.

Answer 10

true

Question 11

Physiological cysts types

Answer 11

Follicular cysts

Corpus luteum cyst

Question 12

Follicular cysts

Answer 12

commonest type of ovarian cyst

due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle

Question 13

Follicular cysts commonly regress after several menstrual cycles

Answer 13

true

Question 14

Corpus luteum cyst

Answer 14

during the menstrual cycle if pregnancy doesn’t occur the corpus luteum usually breaks down and disappears. If this doesn’t occur the corpus luteum may fill with blood or fluid and form a corpus luteal cyst

more likely to present with intraperitoneal bleeding than follicular cysts

Question 15

Benign germ cell tumours example

Answer 15

Dermoid cyst

also called mature cystic teratomas.

Question 16

Dermoid cyst

Answer 16

Usually lined with epithelial tissue and hence may contain skin appendages, hair and teeth
most common benign ovarian tumour in woman under the age of 30 years
median age of diagnosis is 30 years old
bilateral in 10-20%
usually asymptomatic. Torsion is more likely than with other ovarian tumours

Question 17

Benign epithelial tumours

Arise from

Answer 17

the ovarian surface epithelium

Question 18

Benign epithelial tumours subtypes

Answer 18

Serous cystadenoma

Mucinous cystadenoma

Question 19

Serous cystadenoma

Answer 19

the most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma)
bilateral in around 20%

Question 20

Mucinous cystadenoma

Answer 20

second most common benign epithelial tumour
they are typically large and may become massive
if ruptures may cause pseudomyxoma peritonei

Question 21

There are 4 main types of ovarian tumours

Answer 21

surface derived tumours
germ cell tumours
sex cord-stromal tumours
metastasis

Question 22

Surface derived tumours

These account for around ?% of ovarian tumours

Answer 22

Surface derived tumours

These account for around 65% of ovarian tumours

Question 23

surface derived tumours (benign) include

Answer 23

Serous cystadenoma
Mucinous cystadenoma
Brenner tumour

Question 24

surface derived tumours (malignant) include

Answer 24

Mucinous cystadenocarcinoma

Serous cystadenocarcinoma

Question 25

Serous cystadenoma

Answer 25

Most common benign ovarian tumour, often bilateral

Cyst lined by ciliated cells (similar to Fallopian tube)

Question 26

Serous cystadenocarcinoma

Answer 26

Often bilateral

Psammoma bodies seen (collection of calcium)

Question 27

Mucinous cystadenoma

Answer 27

Cyst lined by mucous-secreting epithelium (similar to endocervix)

Question 28

Mucinous cystadenocarcinoma

Answer 28

May be associated with pseudomyxoma peritonei (although mucinous tumour of appendix is the more common cause)

Question 29

Brenner tumour

Answer 29

Contain Walthard cell rests (benign cluster of epithelial cells), similar to transitional cell epithelium. Typically have ‘coffee bean’ nuclei.

Question 30

Germ cell tumours These are more common

Answer 30

in adolescent girls and are account for 15-20% of tumours.

Question 31

Germ cell tumours types

Answer 31

Teratoma
Dysgerminoma
Yolk sac tumour
Choriocarcinoma

Question 32

All germ cell tumours are malginant

Answer 32

sort of true,
all malignant bar mature teratoma (most common type is mature teratoma which is benign)
immature - malignant

Question 33

Teratoma

Answer 33

Account for 90% of germ cell tumours

Contain a combination of ectodermal (e.g. hair), mesodermal (e.g. bone) and endodermal tissue

Question 34

Dysgerminoma

Answer 34

Most common malignant germ cell tumour
Histological appearance similar to that of testicular seminoma
Associated with Turner’s syndrome
Typically secrete hCG and LDH

Question 35

Yolk sac tumour

Answer 35

Typically secrete AFP

Schiller-Duval bodies on histology are pathognomonic

Question 36

Choriocarcinoma

Answer 36

Rare tumour that is part of the spectrum gestational trophoblastic disease
Typically have increased hCG levels
Often characterised by early haematogenous spread to the lungs

Question 37

Sex cord-stromal tumours

Represent around 3-5% of ovarian tumours. Often produce hormones.

Answer 37

true

Question 38

Sex cord-stromal tumours - types

Answer 38

Granulosa cell tumour
Sertoli-Leydig cell tumour
Fibroma

Question 39

Granulosa cell tumour

Answer 39

Malignant
Produces oestrogen leading to precocious puberty if in children or endometrial hyperplasia in adults.
Contains Call-Exner bodies (small eosinophilic fluid-filled spaces between granulosa cells)

Question 40

Sertoli-Leydig cell tumou

Answer 40

Benign
Produces androgens → masculinizing effects
Associated with Peutz-Jegher syndrome

Question 41

Fibroma

Answer 41

Benign
Associated with Meigs’ syndrome (ascites, pleural effusion)
Solid tumour consisting of bundles of spindle-shaped fibroblasts
Typically occur around the menopause, classically causing a pulling sensation in the pelvis

Question 42

Metastatic tumours

Account for around 5% of tumours.

Answer 42

true

Question 43

Krukenberg tumour

Answer 43

Malignant

Metastases from a gastrointestinal tumour resulting in a mucin-secreting signet-ring cell adenocarcinoma

Question 44

The initial imaging modality for suspected ovarian cysts/tumours is
The report will usually report that the cyst is either:

Answer 44

ultrasound.
The report will usually report that the cyst is either:
simple: unilocular, more likely to be physiological or benign
complex: multilocular, more likely to be malignant

Question 45

Ovarian enlargement: management depends on

Answer 45

the age of the patient and whether the patient is symptomatic.

Question 46

Ovarian enlargement: management - Premenopausal women

Answer 46

a conservative approach may be taken for younger women (especially if < 35 years) as malignancy is less common. If the cyst is small (e.g. < 5 cm) and reported as ‘simple’ then it is highly likely to be benign. A repeat ultrasound should be arranged for 8-12 weeks and referral considered if it persists.

Question 47

Ovarian enlargement: management - Postmenopausal women

Answer 47

by definition physiological cysts are unlikely
any postmenopausal woman with an ovarian cyst regardless of nature or size should be referred to gynaecology for assessment

Question 48

Ovarian torsion may be defined as

Answer 48

the partial or complete torsion of the ovary on it’s supporting ligaments that may in turn compromise the blood supply. If the fallopian tube is also involved then it is referred to as adnexal torsion.

Question 49

Ovarian torsion rx

Answer 49

ovarian mass: present in around 90% of cases of torsion
being of a reproductive age
pregnancy
ovarian hyperstimulation syndrome

Question 50

Ovarian torsion sx

Answer 50

Usually the sudden onset of deep-seated colicky abdominal pain.
Associated with vomiting and distress
fever may be seen in a minority (possibly secondary to adnexal necrosis)
Vaginal examination may reveal adnexial tenderness

Question 51

Ovarian torsion ix

Answer 51

Laparoscopy is usually both diagnostic and therapeutic.

Question 52

Ovarian torsion US shows

Answer 52

whirlpool sign.