Ovarian disorders Flashcards
PCOS rotterdam criteria
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)
presentation of PCOS
Oligomenorrhoea or amenorrhoea
Infertility
Hyperandrogenism:
Obesity (in about 70% of patients with PCOS)
Hirsutism
Acne
Hair loss in a male pattern
other features and complications of PCOS
Insulin resistance and diabetes
Acanthosis nigricans
Cardiovascular disease
Hypercholesterolaemia
Endometrial hyperplasia and cancer
Obstructive sleep apnoea
Depression and anxiety
Sexual problems
PCOS epidemiology
5-10% premenopausal women in UK
PCOS hormonal abnormalities
excess LH
insulin resistance: suppresses hepatic of sex-hormone binding globulin
risk factors for PCOS
diabetes
irregular menstruation
FH of PCOS
DD of hirsutism
Medications, such as phenytoin, ciclosporin, corticosteroids, testosterone and anabolic steroids
Ovarian or adrenal tumours that secrete androgens
Cushing’s syndrome
Congenital adrenal hyperplasia
Obesity
other differentials of PCOS
Premature ovarian failure
Thyroid disease, hypothyroidism
Cushing’s disease
Hyperprolactinaemia
insulin resistance in PCOS
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
management of insulin resistance in PCOS
diet
exercise
weight loss
investigations in PCOS
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
results of hormonal blood tests PCOS
testosterone raised SHBG low LH raised FSH normal progesterone low raised insulin raised LH:FSH normal or raised oestrogen levels
transvaginal USS PCOS
diagnostic features
string of pearls: follicles around ovary
> 12 follicles in one ovary
ovarian volume of more than 10cm3
OGTT results PCOS
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
General management PCOS
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%)
PCOS management if woman wants regular periods
COCP
Cyclical progestogens
PCOS management if woman wants to conceive
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
PCOS management if woman wants treatment for acne and/or hirsutism
COCP
Treatment for acne- retinoids, antibiotics etc as per dermatology
Hair removal methods- waxing, laser treatment
associated complications to monitor for in PCOS
Endometrial hyperplasia and cancer
Infertility
Hirsutism
Acne
Obstructive sleep apnoea
Depression and anxiety
weight loss is a significant part of PCOS management
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.
risk factors for endometrial cancer in PCOS
Obesity
Diabetes
Insulin resistance
Amenorrhoea
reducing endometrial cancer risk in PCOS
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
managing infertility in PCOS
Clomifene
Laparoscopic ovarian drilling
In vitro fertilisation (IVF)
metformin and letrozole limited evidence to support use
ovarian drilling: laparoscopic
gestational diabetes screening
managing hirsutism in PCOS
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)
co-cyprindiol (Dianette)
increases risk of VTE
stop after 3 months
topical eflornithine
facial hirsutism
takes 6-8 weeks to see a significant improvement
hirsutism will stop within two months of stopping eflornithine
management of acne
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)
long-term implications of PCOS
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
risk factors for ovarian cancer
Nulliparity Early menarche Late menopause Hormone replacement therapy containing oestrogen only Smoking Obesity
protective factors ovarian factors ovarian cancer
Multiparity
Combined contraceptive methods
Breastfeeding
genetic component to ovarian cancer
BRCA 1&2
HNPCC (Lynch II syndrome)
risk of malignancy index in ovarian cancer
menopausal status
USS score
CA125
clinical features of ovarian cysts and tumours
incidental and asymptomatic
chronic pain
pressure in bladder/ bowel causing constipation or frequency
acute pain: bleeding into cyst, rupture or torsion
bleedng per vagina
ovarian cyst history
Bloating Change in bowel habit Change in urinary frequency Weight loss Irritable bowel syndrome Bleeding per vagina
ovarian cyst types:
non-neoplastic
benign neoplastic
non-neoplastic types of ovarian cysts
functional
pathological
benign neoplastic types of ovarian cysts
epithelial tumours
benign germ cell tumours
sex-cord stromal tumours
functional types of ovarian cysts
follicular cysts
corpus luteal cysts
pathological types of ovarian cysts
endometrioma
polycystic ovaries
theca lutein cyst
epithelial tumour types
serous cystadenoma
mucinous cystadenoma
brenner tumour
benign germ cell tumours
mature cystic teratoma (Dermoid cyst)
sex-cord stromal tumours
fibroma
follicular cysts
<3cm
represent developing follicle in first half of menstrual cycle
corpus luteal cysts
<5cm
luteal phase of menstrual cycle after formation of corpus luteum
endometrioma
These are also called chocolate cysts and are present in those with endometriosis. There has been bleeding into the cyst resulting in the appearance.
polycystic ovaries
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.
theca lutein cyst
These result as a consequence of markedly raised hCG e.g. molar pregnancy. They regress upon resolution of the raised hCG.
serous cystadenoma
reflects the most common type of malignant ovarian tumour and is usually unilocular with up to 30% being bilateral.
mucinous cystadenoma
these are often multiloculated and usually unilateral.
Brenner tumour
unilateral with a solid grey or yellow appearance.
mature cystic teratoma (Dermoid cyst)
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.
fibroma
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.
management of ovarian cyst in premenopausal women
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.
management of ovarian cyst in postmenopausal women
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
types of ovarian cancer
Serous cystadenocarcinoma – characterised by Psammoma bodies.
Mucinous cystadenocarcinoma – characterised by mucin vacuoles.
investigations for suspected ovarian cancer
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.
investigations for confirmed ovarian cancer
In cases of confirmed cancer, chest x-ray and CT abdomen/pelvis should be undertaken for staging and pre-operative purposes.
management of ovarian cancer
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.
