Ovarian Disease Flashcards
Polycystic ovary syndrome (PCOS) is
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.
Polycystic ovary syndrome (PCOS) sx
subfertility and infertility
menstrual disturbances: oligomenorrhea and amenorrhoea
hirsutism, acne (due to hyperandrogenism)
obesity
acanthosis nigricans (due to insulin resistance)
Polycystic ovary syndrome (PCOS) ix
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
Polycystic ovarian syndrome: management - General
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
Polycystic ovarian syndrome: management - Hirsutism and acne
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
Polycystic ovarian syndrome: management
Infertility
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
There is a potential risk of multiple pregnancies with anti-oestrogen* therapies
true
anti-oestrogen therapies work by?
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
Benign ovarian cysts are extremely common. What types?
physiological cysts, benign germ cell tumours, benign epithelial tumours and benign sex cord stromal tumours.
Complex (i.e. multi-loculated) ovarian cysts should be biopsied to exclude malignancy.
true
Physiological cysts types
Follicular cysts
Corpus luteum cyst
Follicular cysts
commonest type of ovarian cyst
due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
Follicular cysts commonly regress after several menstrual cycles
true
Corpus luteum cyst
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
Benign germ cell tumours example
Dermoid cyst
also called mature cystic teratomas.
Dermoid cyst
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
Benign epithelial tumours
Arise from
the ovarian surface epithelium
Benign epithelial tumours subtypes
Serous cystadenoma
Mucinous cystadenoma
Serous cystadenoma
the most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma)
bilateral in around 20%
Mucinous cystadenoma
second most common benign epithelial tumour
they are typically large and may become massive
if ruptures may cause pseudomyxoma peritonei
There are 4 main types of ovarian tumours
surface derived tumours
germ cell tumours
sex cord-stromal tumours
metastasis
Surface derived tumours
These account for around ?% of ovarian tumours
Surface derived tumours
These account for around 65% of ovarian tumours
surface derived tumours (benign) include
Serous cystadenoma
Mucinous cystadenoma
Brenner tumour
surface derived tumours (malignant) include
Mucinous cystadenocarcinoma
Serous cystadenocarcinoma
Serous cystadenoma
Most common benign ovarian tumour, often bilateral
Cyst lined by ciliated cells (similar to Fallopian tube)
Serous cystadenocarcinoma
Often bilateral
Psammoma bodies seen (collection of calcium)
Mucinous cystadenoma
Cyst lined by mucous-secreting epithelium (similar to endocervix)
Mucinous cystadenocarcinoma
May be associated with pseudomyxoma peritonei (although mucinous tumour of appendix is the more common cause)
Brenner tumour
Contain Walthard cell rests (benign cluster of epithelial cells), similar to transitional cell epithelium. Typically have ‘coffee bean’ nuclei.
Germ cell tumours These are more common
in adolescent girls and are account for 15-20% of tumours.
Germ cell tumours types
Teratoma
Dysgerminoma
Yolk sac tumour
Choriocarcinoma
All germ cell tumours are malginant
sort of true,
all malignant bar mature teratoma (most common type is mature teratoma which is benign)
immature - malignant
Teratoma
Account for 90% of germ cell tumours
Contain a combination of ectodermal (e.g. hair), mesodermal (e.g. bone) and endodermal tissue
Dysgerminoma
Most common malignant germ cell tumour
Histological appearance similar to that of testicular seminoma
Associated with Turner’s syndrome
Typically secrete hCG and LDH
Yolk sac tumour
Typically secrete AFP
Schiller-Duval bodies on histology are pathognomonic
Choriocarcinoma
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
Sex cord-stromal tumours
Represent around 3-5% of ovarian tumours. Often produce hormones.
true
Sex cord-stromal tumours - types
Granulosa cell tumour
Sertoli-Leydig cell tumour
Fibroma
Granulosa cell tumour
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)
Sertoli-Leydig cell tumou
Benign
Produces androgens → masculinizing effects
Associated with Peutz-Jegher syndrome
Fibroma
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
Metastatic tumours
Account for around 5% of tumours.
true
Krukenberg tumour
Malignant
Metastases from a gastrointestinal tumour resulting in a mucin-secreting signet-ring cell adenocarcinoma
The initial imaging modality for suspected ovarian cysts/tumours is
The report will usually report that the cyst is either:
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
Ovarian enlargement: management depends on
the age of the patient and whether the patient is symptomatic.
Ovarian enlargement: management - Premenopausal women
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.
Ovarian enlargement: management - Postmenopausal women
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
Ovarian torsion may be defined as
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.
Ovarian torsion rx
ovarian mass: present in around 90% of cases of torsion
being of a reproductive age
pregnancy
ovarian hyperstimulation syndrome
Ovarian torsion sx
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
Ovarian torsion ix
Laparoscopy is usually both diagnostic and therapeutic.
Ovarian torsion US shows
whirlpool sign.
