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Gynaecology > Ovarian disorders > Flashcards

Ovarian disorders Flashcards

1
Q

PCOS rotterdam criteria

A

2/3
Oligoovulation or anovulation, presenting with irregular or absent menstrual periods

Hyperandrogenism, characterised by hirsutism and acne

Polycystic ovaries on ultrasound (or ovarian volume of more than 10cm3)

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2
Q

presentation of PCOS

A

Oligomenorrhoea or amenorrhoea

Infertility

Hyperandrogenism:
Obesity (in about 70% of patients with PCOS)
Hirsutism
Acne

Hair loss in a male pattern

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3
Q

other features and complications of PCOS

A

Insulin resistance and diabetes

Acanthosis nigricans

Cardiovascular disease

Hypercholesterolaemia

Endometrial hyperplasia and cancer

Obstructive sleep apnoea

Depression and anxiety

Sexual problems

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4
Q

PCOS epidemiology

A

5-10% premenopausal women in UK

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5
Q

PCOS hormonal abnormalities

A

excess LH

insulin resistance: suppresses hepatic of sex-hormone binding globulin

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6
Q

risk factors for PCOS

A

diabetes
irregular menstruation
FH of PCOS

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7
Q

DD of hirsutism

A

Medications, such as phenytoin, ciclosporin, corticosteroids, testosterone and anabolic steroids

Ovarian or adrenal tumours that secrete androgens

Cushing’s syndrome

Congenital adrenal hyperplasia

Obesity

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8
Q

other differentials of PCOS

A

Premature ovarian failure

Thyroid disease, hypothyroidism

Cushing’s disease

Hyperprolactinaemia

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9
Q

insulin resistance in PCOS

A

high insulin results in high levels of androgen release

insulin suppresses SHBG production by liver

SHBG suppresses androgens

insulin resistance, reduced SHBG. hyperandrogenism

high insulin, anovulation and multiple partially developed follicles

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10
Q

management of insulin resistance in PCOS

A

diet
exercise
weight loss

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11
Q

investigations in PCOS

A

Testosterone

Free androgen index

Sex hormone-binding globulin

Luteinizing hormone

Follicle-stimulating hormone

Prolactin (may be mildly elevated in PCOS)

Thyroid-stimulating hormone

Do these tests in the follicular phase

Offer screening for impaired glucose tolerance

Pelvic USS

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12
Q

results of hormonal blood tests PCOS

A 
testosterone raised
SHBG low
LH raised
FSH normal
progesterone low 
raised insulin
raised LH:FSH
normal or raised oestrogen levels
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13
Q

transvaginal USS PCOS

diagnostic features

A

string of pearls: follicles around ovary

> 12 follicles in one ovary
ovarian volume of more than 10cm3

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14
Q

OGTT results PCOS

A

2 hour 75g OGTT

Impaired fasting glucose – fasting glucose of 6.1 – 6.9 mmol/l (before the glucose drink)

Impaired glucose tolerance – plasma glucose at 2 hours of 7.8 – 11.1 mmol/l

Diabetes – plasma glucose at 2 hours above 11.1 mmol/l

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15
Q

General management PCOS

A

Reduce risk associated with obesity, T2DM, hypercholesterolaemia, CVD:
Weight loss

Low glycaemic index, calorie-controlled diet

Exercise

Smoking cessation

Antihypertensive medications where required

Statins where indicated (QRISK >10%)

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16
Q

PCOS management if woman wants regular periods

A

COCP

Cyclical progestogens

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17
Q

PCOS management if woman wants to conceive

A

Reduce BMI to <30

Start folic acid

Baseline fertility assessment, including semen analysis on partner

Refer to fertility services

May require ovulation induction

Metformin controversial

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18
Q

PCOS management if woman wants treatment for acne and/or hirsutism

A

COCP

Treatment for acne- retinoids, antibiotics etc as per dermatology

Hair removal methods- waxing, laser treatment

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19
Q

associated complications to monitor for in PCOS

A

Endometrial hyperplasia and cancer

Infertility

Hirsutism

Acne

Obstructive sleep apnoea

Depression and anxiety

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20
Q

weight loss is a significant part of PCOS management

A

Weight loss alone can result in ovulation and restore fertility and regular menstruation, improve insulin resistance, reduce hirsutism and reduce the risks of associated conditions.

Orlistat may be used to help weight loss in women with a BMI above 30.

Orlistat is a lipase inhibitor that stops the absorption of fat in the intestines.

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21
Q

risk factors for endometrial cancer in PCOS

A

Obesity

Diabetes

Insulin resistance

Amenorrhoea

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22
Q

reducing endometrial cancer risk in PCOS

A

Mirena coil for continuous endometrial protection

Inducing a withdrawal bleed at least every 3 – 4 months with either:

Cyclical progestogens (e.g. medroxyprogesterone acetate 10mg once a day for 14 days)

Combined oral contraceptive pill

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23
Q

managing infertility in PCOS

A

Clomifene

Laparoscopic ovarian drilling

In vitro fertilisation (IVF)

metformin and letrozole limited evidence to support use

ovarian drilling: laparoscopic

gestational diabetes screening

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24
Q

managing hirsutism in PCOS

A

weight loss
co-cyprindiol (Dianette)
topical eflornithine

Electrolysis

Laser hair removal

Spironolactone (mineralocorticoid antagonist with anti-androgen effects)

Finasteride (5α-reductase inhibitor that decreases testosterone production)

Flutamide (non-steroidal anti-androgen)

Cyproterone acetate (anti-androgen and progestin)

25
Q

co-cyprindiol (Dianette)

A

increases risk of VTE

stop after 3 months

26
Q

topical eflornithine

A

facial hirsutism
takes 6-8 weeks to see a significant improvement
hirsutism will stop within two months of stopping eflornithine

27
Q

management of acne

A 
co-cyprindiol first line
Topical adapalene (a retinoid)

Topical antibiotics (e.g. clindamycin 1% with benzoyl peroxide 5%)

Topical azelaic acid 20%

Oral tetracycline antibiotics (e.g. lymecycline)

28
Q

long-term implications of PCOS

A

Metabolic disorders, impaired glucose tolerance and T2DM

CVD

OSA

Infertility

Recurrent miscarriage

Pregnancy complications, pre-eclampsia and gestational diabetes

Endometrial cancer, exposure to high levels of oestrogen

Psychological disorders: anxiety and depression

29
Q

risk factors for ovarian cancer

A 
Nulliparity
Early menarche
Late menopause
Hormone replacement therapy containing oestrogen only
Smoking
Obesity
30
Q

protective factors ovarian factors ovarian cancer

A

Multiparity
Combined contraceptive methods
Breastfeeding

31
Q

genetic component to ovarian cancer

A

BRCA 1&2

HNPCC (Lynch II syndrome)

32
Q

risk of malignancy index in ovarian cancer

A

menopausal status
USS score
CA125

33
Q

clinical features of ovarian cysts and tumours

A

incidental and asymptomatic
chronic pain
pressure in bladder/ bowel causing constipation or frequency
acute pain: bleeding into cyst, rupture or torsion
bleedng per vagina

34
Q

ovarian cyst history

A 
Bloating
Change in bowel habit
Change in urinary frequency
Weight loss
Irritable bowel syndrome
Bleeding per vagina
35
Q

ovarian cyst types:

A

non-neoplastic

benign neoplastic

36
Q

non-neoplastic types of ovarian cysts

A

functional

pathological

37
Q

benign neoplastic types of ovarian cysts

A

epithelial tumours
benign germ cell tumours
sex-cord stromal tumours

38
Q

functional types of ovarian cysts

A

follicular cysts

corpus luteal cysts

39
Q

pathological types of ovarian cysts

A

endometrioma
polycystic ovaries
theca lutein cyst

40
Q

epithelial tumour types

A

serous cystadenoma
mucinous cystadenoma
brenner tumour

41
Q

benign germ cell tumours

A

mature cystic teratoma (Dermoid cyst)

42
Q

sex-cord stromal tumours

A

fibroma

43
Q

follicular cysts

A

<3cm

represent developing follicle in first half of menstrual cycle

44
Q

corpus luteal cysts

A

<5cm

luteal phase of menstrual cycle after formation of corpus luteum

45
Q

endometrioma

A

These are also called chocolate cysts and are present in those with endometriosis. There has been bleeding into the cyst resulting in the appearance.

46
Q

polycystic ovaries

A

An ultrasound diagnosis. The ovaries contrain more than 12 antral follicles, or ovarian volume greater than 10ml. The classic ‘ring of pearls’ sign is seen on ultrasound scanning. PCO is present as one of the features of polycystic ovarian syndrome (Rotterdam criteria criteria). Isolated PCO does not equate to PCOS.

47
Q

theca lutein cyst

A

These result as a consequence of markedly raised hCG e.g. molar pregnancy. They regress upon resolution of the raised hCG.

48
Q

serous cystadenoma

A

reflects the most common type of malignant ovarian tumour and is usually unilocular with up to 30% being bilateral.

49
Q

mucinous cystadenoma

A

these are often multiloculated and usually unilateral.

50
Q

Brenner tumour

A

unilateral with a solid grey or yellow appearance.

51
Q

mature cystic teratoma (Dermoid cyst)

A

10% are bilateral, usually occur in young women and occur frequently in pregnancy. As germ cell in origin they can contain teeth, hair, skin and bone.

52
Q

fibroma

A

the most common stromal tumour. Important to know about as up to 40% present with Meig’s syndrome which is the association between these tumours and ascites/pleural effusion.

53
Q

management of ovarian cyst in premenopausal women

A

CA125 does not need to be undertaken when the diagnosis of a simple ovarian cyst has been made ultrasonographically. The CA125 can be raised by anything that irritates the peritoneum, so in premenopause there are numerous benign triggers for an increase.
Lactate dehydrogenase, alphafetoprotein and hCG should be measured in all women under 40 due to the possibility of germ cell tumours.
Rescan a cyst in 6 weeks. If it is persistent then monitor with ultrasound an CA125 3-6 monthly and calculate RMI.
If persistent or over 5cm consider laparoscopic cystectomy or oophorectomy.

54
Q

management of ovarian cyst in postmenopausal women

A 
Low RMI (less than 25): follow up for 1 year with ultrasound and CA125 if less than 5cm.
Moderate RMI (25-250): bilateral oophorectomy and if malignancy found then staging is required (with completion surgery of hysterectomy, omentectomy +/- lymphadenectomy).
High RMI (over 250): referral for staging laparotomy
55
Q

types of ovarian cancer

A

Serous cystadenocarcinoma – characterised by Psammoma bodies.
Mucinous cystadenocarcinoma – characterised by mucin vacuoles.

56
Q

investigations for suspected ovarian cancer

A

All patients with suspected ovarian cancer should have basic blood tests included FBC, U&E, LFT and albumin. In the UK, NICE recommends abdominal and pelvic ultrasound for pelvic masses, from which the RMI can be calculated.

57
Q

investigations for confirmed ovarian cancer

A

In cases of confirmed cancer, chest x-ray and CT abdomen/pelvis should be undertaken for staging and pre-operative purposes.

58
Q

management of ovarian cancer

A

Surgery – staging laparotomy for those with a high RMI with attempt to debulk the tumour.
Adjuvant chemotherapy – recommended for all patients apart from those with early, low grade disease and uses platinum based compounds.
Follow up – involves clinical examination and monitoring of CA125 level for 5 years with intervals between visits becoming further apart according to risk of recurrence.

Gynaecology (10 decks)

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