Ovarian Disorders

Question 1

Ovarian Cyst

Answer 1

• Definition:
  
  • fluid filled sac within the ovaries most commonly related to ovulation. Most common during reproductive years
• Types:
  
  • Follicular: most common, occur when follicles fail to rupture & continue to grow
  • Corpus luteal: fail to degenerate after ovulation
• S/sxs:
  
  • most are asymptomatic
  • may have lower abd pain, dyspareunia
• PE:
  
  • unilateral pelvic pain/tenderness
  • mobile palpable cystic adnexal mass
• Dx:
  
  • Transvaginal US: follicular are smooth & thin walled, corpus luteal are complex & Thicker walled
  • hCG to r/o pregnancy
• Tx:
  
  • Most resolve spontaneously in a few weeks
  • Premenopausal: cycle suppression to prevent them from happening
  • Simple cyst: supportive (rest, NSAIDs,) with repeat US
  • Loculated cyst: check CA-125 (for malignancy) & refer to GYN
  • *Cysts in postmenopausal women are malignant until proven otherwise

Question 2

Ruptured Ovarian Cyst

Answer 2

• S/sxs:
  
  • *Sudden onset
  • Unilateral lower abd pain: sharp, focal, may occur during sexual activity
  • Abnormal uterine bleeding
• Pe:
  
  • unilateral pelvic pain/tenderness
  • mobile palpable cystic adnexal mass (sometimes)
• Dx:
  
  • Transvaginal US: adnexal mass & pelvic fluid
  • hCG to r/o pregnancy
• Tx:
  
  • uncomplicated: Observation, analgesics, rest
  • Significant hemoperitoneum: hospitalization, observation, fluid replacement
  • Unstable: laparoscopy, cystectomy

Question 3

Polycystic Ovarian Syndrome: definition, pathophys, comorbidities, epidemiology

Answer 3

• Definition:
  
  • hormonal disorder among women of reproductive age characterized by bilateral cystic ovaries (sometimes but not always), insulin resistance, & hyperandrogenism
• Pathophys:
  
  • increased LH -→ increased testosterone production; decreased FSH → follicular degeneration & decreased ovulation which causes bilateral cystic ovaries
• Comorbidities:
  
  • infertility, endometrial carcinoma, abnormal uterine bleeding, obesity (50%), emotional risks, virilization syndrome, metabolic syndrome, DMII, OSA, CV disease, HTN, NASH
• Epidemiology:
  
  • most common endocrine condition in women age 18-44yo, affects ~7% of women in the US (`28% in obese women), ~7%5 of all cases of anovulatory infertility

Question 4

Polycystic Ovarian Syndrome: S/sxs & PE

Answer 4

• S/sxs:
  
  • increased androgens:
    
    • hirsutism, cystic acne, alopecia, baldness, voice deepening, increased muscle mass, clitoromegaly
  • menstrual dysfunction:
    
    • oligomenorrhea (cycles > 35 days), amenorrhea (absence of menstruation for 6-12 months) or menorrhagia (heavy or prolonged bleeding
  • Insulin resistance: DM II,obesity, HTN
• PE:
  
  • Skin:
    
    • Jawline, back and chest cystic acne
  • Hair:
    
    • hirsutism (face, posterior back, abdomen), androgenic alopecia
  • Acanthosis Nigricans
  • Central Adiposity:
    
    • apple-shaped body
  • Bilaterally enlarged, smooth, mobile ovaries on bimanual examination→ “string of pearls” appearance

Question 5

Polycystic Ovarian Syndrome: Dx & Tx

Answer 5

• Dx:
  
  • labs to order:
    
    • free testosterone -→ increased; sex hormone binding globulin → decreased
    • LH/FSH ratio: > 2
    • A1C, fasting glucose, 2H OGTT
    • UPT to r/o pregancy
    • TSH to r/o thyroid disorder; Prolactin to r/o prolactinoma; 17-hydroxyprogesterone to r/o congenital adrenal hyperplasia

Pelvic US:

• -12+ follicles 2-9mm in diameter or ovary with a volume >10mL
• -”String of pearls” appearance
• *if pt does not want an US (invasive) can get anti-Mullerian Hormone (AMH): if > 4.5 this is diagnostic for PCOS

Hyperandrogenism: baseline for diagnosis

• -Oligomenorrhea
• -Polycystic ovaries
• *diagnostics SUPPORT dx but are not necessary

Tx if pregnancy NOT desired:

• -lifestyle changes: diet, exercise, weight loss
• -Oral contraception = mainstay
• -Metform=gold standard, use prophylactically
• -Anti-androgenic agent: spironolactone
• -Hirsutism: electrolysis & light based therapies, spironolactone (teratogenic→caution)

Tx if pregnancy is desired:

• -Clomiphene citrate or letrozole: causes ovulation, but requires a lot of monitoring (refer to OBGYN)
• -metformin: may improve menstrual frequency

Question 6

Ovarian Torsion

Answer 6

• Definition:
  
  • complete or partial rotation of the ovary on its ligamental supports → compromise in ovarian blood flow → infarction
• Etiology:
  
  • usually a mechanical cause in pts with functional ovarian cysts or ovarian neoplasms (esp if >5cm)
• S/sxs:
  
  • acute onset
  • unilateral pelvic pain
  • N/V
• PE:
  
  • abd tenderness
  • adnexal mass
• Dx:
  
  • US with doppler = initial test of choice, decreased ovarian blood flow
• Tx:
  
  • Laparoscopy with detorsion → restores blood flow to ovary
  • Salpingo-oophorectomy if the ovary has been hypoperfused for too long and has become necrotic or if malignant tissue is present.

Question 7

Ovarian Cancer (Ovarian Adenocarcinoma)

Answer 7

• Types:
  
  • Epithelial Cell = most common
• Etiology:
  
  • genetic susceptibility (15%): BRCA1 & BRCA2, HNPCC
  • Spontaneous somatic mutation (85%)
• S/sxs:
  
  • rarely symptomatic until late in disease course
  • abd bloating & distension
  • changes in bowel/bladder fxn
  • anorexia, ascites
  • Can’t button top of pants
• PE:
  
  • Sister Mary Joseph sign: palpable nodule bulging into the umbilical as a result of metastasis of a malignant cancer in the pelvis or abdomen
  • If you can feel an ovary in a postmenopausal woman that is cancer until proven otherwise
• Staging:
  
  • IA: growth limited to one ovary
  • IB: growth limited to both ovaries
  • IC: tumor limited to one or both ovaries
• Dx:
  
  • CT scan, Fagotti score: laparoscopic assessment
• Monitoring Progression:
  
  • CA-124 (biochemical), imaging (CT/PET), PE, increase symptoms
• Tx:
  
  • Primary tumor reductive surgery (PDS):
    
    • surgery → chemotherapy (optimal = no residual cancer > 1cm)
  • Neoadjuvant chemotherapy (NACT):
    
    • chemotherapy → surgery → chemotherapy
  • Biologic therapies:
    
    • alter how cancer cells function
  • Chemotherapy:
    
    • Carboplatin, taxol (Paclitaxel) IV q 3weeks x 6 treatments
  • *Cancer will recur → becomes a chronic disease

Question 8

Protective Factors Against Ovarian Cancer

Answer 8

Tubal ligation, hysterectomy, multiple pregnancies, pregnancy before 35 yo, OCPs, reduced number of ovulatory cycles