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Women's health > Ovarian disorders > Flashcards

Ovarian disorders Flashcards

1
Q

Symptoms of functional ovarian cysts are result of:

A
  1. Rupture of contents (chemical peritonitis)
  2. Torsion of enlarged ovaries
  3. Mechanical pressure
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2
Q

possible symptoms of functional ovarian cysts

A
  • Menstrual irregularities
  • Pelvic pressure or pain
  • Large - constipation or urinary frequency
    *
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3
Q

how to dx functional ovarian cysts

A
  • possible on pelvic exam
  • Pelvic US
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4
Q

MC functional ovarian cyst

A

follicular cysts

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5
Q

causes of follicular cysts

A
  • Due to failure in ovulation
  • Incompletely developed - does not rupture
  • Fluid does not get completely reabsorbed
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6
Q

s/s of follicular cysts

A
  • Usually asx
  • bleeding and torsion
  • Large cysts - aching pelvic pain, dyspareunia
  • abnml uterine bleeding with disturbance of ovulation
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7
Q

tx for follicular cysts

A
  • observation; symptomatic; resolve spontaneously < 2 mo
  • OCPs - may not speed resolution of cysts
  • Aspiration - done in past; not thought to help dx or reduce recurrence
  • Cystectomy - for large or painful cysts
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8
Q

causes of Corpus Luteum Cysts

A
  • accumulation of fluid inside a corpus luteum
  • May be more likely if taking clomiphene (Clomid)
  • Failure of corpus luteum to involute
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9
Q

s/s of corpus luteum cysts

A
  1. asx or local pain, tenderness,
    amenorrhea or delayed menstruation
    - May lead to ovarian torsion or cyst rupture and bleeding - Can mimic an ectopic pregnancy
    - Severe bleeding/rupture - acute abdomen, hypovolemic shock
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10
Q

tx for corpus luteum cysts

A
  • Symptomatic; resolve spontaneously < 2m
  • OCPs - recommended but questionable benefit
  • Surgical intervention - if hemorrhaging or torsion
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11
Q

causes of theca lutein cysts

A
  • elevated levels of hCG
  • Hydatidiform mole, choriocarcinoma, multiple gestation, hCG therapy
  • MC bilaterally, filled with clear fluid
  • May occur as multiple simultaneous cysts
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12
Q

s/s of theca lutein cysts

A
  • usually minimal sx
  • May have pelvic heaviness or aching
  • May see rupture and bleeding or ovarian torsion
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13
Q

tx for theca lutein cysts

A
  • sx; underlying cause
  • Gradually resolve as hCG return to normal
  • months to resolve
  • Surgical intervention - if torsion or hemorrhage
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14
Q

endometric foci on ovarian surface
Seen in pts with endometriosis
May develop fibrous enclosure
Often called “chocolate cysts”

A

Endometriomas

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15
Q

s/s of Endometriomas

A
  • pelvic pain, dyspareunia, dysmenorrhea, infertility
  • CA-125 may be elevated
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16
Q

tx for endometriomas

A

as for endometriosis
May be removed laparoscopically

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17
Q
  • Filled with various types of tissue - Fatty material, hair, teeth, bits of bone, cartilage
  • 10-15% of ovarian cysts in premenopausal women
  • Rarely neoplastic but may rupture
A

Dermoid Cysts

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18
Q
  • Develop from cells on the outer surface of the ovary
  • Benign but can grow very large and cause pain
A

Cystadenomas

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19
Q
  • Persistent anovulation
  • Enlarged polycystic ovaries
  • Secondary amenorrhea or oligomenorrhea
  • Obesity, hirsutism, infertility
A

PCOS - Stein-Leventhal Syndrome

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20
Q

prevalnce of PCOS?

A

6.5-10%

  • 50% are hirsute
  • +50% are obese
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21
Q

cause of PCOS?

A
  1. Thought to be complex multivariable disorder, similar to T2DM or MetS
    - genetic and environmental factors
    - 20-40% prevalence in 1st degree relatives
  2. HPO dysfunction - Altered LH action, altered folliculogenesis
  3. Insulin resistance and obesity
  4. Hyperandrogenism
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22
Q

criteria diagnosis for PCOS

A

At least 2 of the following:
1. Oligo-ovulation (oligomenorrhea) or anovulation (amenorrhea)
1. Hyperandrogenism
1. Polycystic ovaries on US
- “Oyster ovaries” - enlarged and sclerocystic ovaries; smooth, pearl-white surfaces w/o indentations

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23
Q

obstetric symptoms of PCOS

A
  1. Leading cause of female infertility
  2. inc early pregnancy loss - 30-50% (15% baseline)
  3. inc pregnancy complications
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24
Q

gynecologic symptoms of PCOS

A
  • Menstrual abnormalities
  • Ovarian cysts
  • Pelvic pain or pressure
  • Endometrial neoplasia
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25
Q

psych symptoms of PCOS

A
  • Anxiety, depression
  • Low self-esteem
  • Negative body image
  • Dec quality of life
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26
Q

Constitutional/Endocrine sx of PCOS

A
  1. Wt gain or obesity
  2. Insulin resistance
  3. Sleep apnea
  4. NAFLD
  5. Dyslipidemia
  6. MetS
  7. Usually do not see signs of virilization - NO inc muscle mass, dec breast size, deepened voice, clitoromegaly
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27
Q

Dermatologic sx of PCOS

A
  1. Hirsutism - coarse, dark hairs in male pattern (face, chest, stomach, back) - 70-80% cases - 2o PCOS
  2. Acne, oily skin, dandruff
  3. Hair loss - Male pattern baldness; thinning hair
  4. Acanthosis nigricans
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28
Q

w/u for PCOS

A
  1. Hormonal
    - Androgens - mildly elevated
    - SHBG - decreased
    - Inc LH:FSH ratio
  2. Lipid abnormalities - high LDL and TG, low HDL
  3. Insulin resistance and type II DM
  4. Pelvic US - multiple follicles/cysts BL; nml possible
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29
Q

Signs of anovulation on diagnostic testing for PCOS

A
  • Persistently high LH and low FSH
  • Low day-21 progesterone level
  • Anovulation on sonographic follicular monitoring
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30
Q

observation would be best for what type of PCOS pt?
maintenance?

A
  • with regular cycle intervals (8-12/yr) and mild hyperandrogenism who do not desire to conceive
  • Regular screening for lipids, DM, weight
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31
Q

lifestyle changes for PCOS

A
  1. 5-10% wt loss can restore normal ovulatory cycles in some patients
  2. Reduces insulin and androgen levels
  3. Well-balanced hypocaloric diet instead of low-carb/high-protein - Limited processed foods and foods with added sugars
  4. Regular aerobic exercise
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32
Q

types of hormonal therapy for PCOS

A
  1. COC
  2. progesterone-only therapy
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33
Q

MOA of COC for PCOS

A
  1. Induce regular menses and antagonizes endometrial proliferation
  2. Reduce androgen lvl → suppress FSH/LH release, increase SHBG
    - Chose COCs with progestins that have less androgenic properties
    - Norethindrone, norgestimate, desogestrel, drospirenone
  3. vaginal ring/patch - not well studied
  4. If not pregnant - progesterone to cause withdrawal bleed before COC
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34
Q

for suspected PCOS, If pt has not had menses for > 4 weeks what must you obtain?

A

pregnancy test

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35
Q
  1. Oral OR IUD
  2. Mainly used in patients who cannot take COC
  3. Helps prevent endometrial hyperplasia/cancer
    - Some forms can be used for contraception
    - Does not tx hyperandrogenic sx
A

Progesterone-only therapy

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36
Q

Insulin sensitizing agents for PCOS?

A
  1. metformin - May inc spontaneous ovulation induction; GI upset, lactic acidosis
  2. rosiglitazone (Avandia) / pioglitazone (Actos) - Less well-studied, concerns over SE; Category C in pregnancy
  3. GLP-1 agonists - wt loss
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37
Q

tx for NAFLD/NASH in PCOS?

A
  • Metformin - can reduce risk, reduce progression
  • Weight loss can also improve metabolic/hepatic function
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38
Q

tx for hirsutism

A
  1. COCs - lower androgens, inc SHBG; 1st-line/initial tx
  2. GnRH agonists - lower androgen lvl; Expensive and undesirable SE of bone loss, menopausal s/s
  3. Depilation - hair removal above skin surface; Shaving, topical chemical depilatories
  4. Epilation - removal of entire hair shaft; Mechanical, electrolysis, laser
  5. Eflornithine Hydrochloride (Vaniqa)
  6. Spironolactone
  7. Finasteride, dutasteride
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39
Q

Antimetabolite topical cream applied BID
Inhibits enzyme for hair follicle division and function
Does not permanently remove hair
Expensive

which tx for hirsutism

A

Eflornithine Hydrochloride (Vaniqa)

40
Q

SE and CI of Eflornithine Hydrochloride (Vaniqa)

A
  • SE - acne, burning, redness, ingrown hair
  • CI - patients with known hypersensitivity
41
Q

Often used in combination with contraceptives
6-month trial of COC followed by this medication
May cause metrorrhagia
Not safe to fetus if patient should become pregnant

what hirsutism tx?

A

spironolactone

42
Q

Decreased testosterone conversion; may cause decreased libido
May also help with male-pattern hair loss
Not safe to male fetus if pt becomes pregnant

which hirsutism tx?

A

Finasteride, dutasteride

5-alpha-reductase inhibitors

43
Q

tx for acne in PCOS

A

involves lowering androgen levels

  1. COC
  2. Antiandrogen agents - spironolactone, 5-ɑ reductase inhibitors
  3. Adjuvant - topical retinoids, BPO, isotretinoin, topical or systemic abx
44
Q

tx for acanthosis nigricans in PCOS?

A
  • Tx aimed at improving insulin sensitivity
  • Topical treatments usually do not improve
45
Q

2 Novel and Emerging Therapies for PCOS

A
  1. Myo-Inositol - dietary supp; Second messenger - may help improve insulin sensitivity
    - maybe help ovulatory frequency, wt loss
  2. NK34 antagonists / Kappa-receptor agonists - slows GnRH pulses
    - showed improved LH and testosterone lvls - No effect on ovulation noted to date
46
Q

before Ovulation Induction, what conservative tx should always be attempted first?

A

wt loss and exercise

47
Q

what 4 medications help with ovulation induction

A
  1. Letrozole (Femara) - 1st-line
  2. Clomiphene citrate (Clomid) - formerly 1st-line
  3. Metformin - used alone or in combo with clomiphene
  4. Exogenous gonadotropins
48
Q

MOA of Letrozole (Femara)

A
  • inhibits aromatase
  • inc production of GnRH → FSH/LH
  • Given days 3-7 of menstrual cycle to produce a larger amount of FSH
49
Q

SE and CI of Letrozole (Femara)

A

SE - hot flashes, fatigue, dizziness, joint pain - tolerable due to short duration
CI - pregnancy (category X), hypersensitivity to drug

50
Q

DDI of letrozole

A

methadone/levomethadone, tamoxifen

51
Q

Pros of letrozole

A

as compared to clomiphene citrate

  1. More monofollicular development
  2. Shorter half-life (48 hours vs. 2 weeks for Clomid)
  3. No direct antiestrogenic adverse effects on endometrium
  4. Lower serum estradiol levels
  5. Higher rates of live birth, esp in obese women
52
Q

which ovulation induction medication is a SERM and binds to hypothalamus, blocking estrogen receptors
Increased production of GnRH → FSH/LH
Acts as an estrogen agonist if estrogen is absent

A

Clomiphene citrate (Clomid) - formerly first-line

53
Q

SE and CI of Clomiphene citrate (Clomid)

A
  1. SE - ovarian enlargement and cysts, hot flashes, bloating, GI upset, breast discomfort, abnormal menses, HA
    - Serious - alopecia, inc risk of ovarian or endometrial CA, ovarian hyperstimulation syndrome, uterine fibroid enlargement
  2. CI - pregnancy (category X), liver disease, undiagnosed abnormal uterine bleeding, ovarian cysts (not due to PCOS)
54
Q

DDI of clomiphene citrate

A

drugs that act on HPO axis - estrogens, SERMs, aromatase inhibitors, gonadotropins, GnRH agonists

55
Q

clomiphene citrate Induces ovulation in ?%, but successful pregnancy in only %

A
  • 75
  • 40
56
Q

used alone or in combo with clomiphene
Category B in pregnancy

which ovulation induction medication

A

metformin

57
Q
  • cause ovulation in 72% and pregnancy in 45%
  • High risk for ovarian hyperstimulation syndrome

which ovulation induction medication

A

Exogenous gonadotropins

58
Q

Main cause of symptoms in Ovarian Hyperstimulation Syndrome?

A

Vascular hyperpermeability - 3rd spacing of fluid

59
Q

s/s of mild ovarian hyperstimulation syndrome

A
  • bloating, N/V/D, weight gain
  • Ovaries enlarged 5-12 cm; mild ascites
60
Q

pt with ovarian hyperstimulation syndrome has increased weight gain (>2 lbs/d), N/V/D, dark urine, oliguria, thirst, dry skin and hair

what is the severity of her s/s?

A

moderate

61
Q

s/s of severe ovarian hyperstimulation syndrome

A

SOB, pleural effusion, severe oliguria, pain in the calf / chest / abdomen, hemoconcentration, thrombosis, respiratory distress

62
Q

tx for Ovarian Hyperstimulation Syndrome

A

Supportive; resolves 1-2 wks after d/c meds
Lower incidence with Clomid than synthetic FSH

63
Q

surgical tx options for PCOS?

A
  1. Laparoscopic ovarian surgery - SE: adhesions
  2. Oophorectomy
64
Q

Creates focal areas of damage in ovary
Cauterization, laser “drilling,” biopsies
May induce ovulation in patients unresponsive to medical therapy

what surgery?

A

Laparoscopic ovarian surgery

65
Q

MCC of ovarian torsion?

A

ovarian enlargement - 50-80%

66
Q

10-22% of ovarian torsion cases occur during ?

A

pregnancy

67
Q
  • A surgical emergency - ischemic condition
  • Prompt dx critical for preserving function
  • May involve ovary alone or oviduct (adnexal torsion)
A

Ovarian Torsion

68
Q
  • sudden onset, severe, unilateral, lower abd. pain
  • Over 50% on right side; may radiate to flank, thigh or groin
  • May develop after episodes of exertion
  • fever, N/V, adnexal mass on exam, vaginal bleeding possible
A

Ovarian Torsion

69
Q

atypical presentation of Ovarian Torsion

A
  • Bilateral, mild or intermittent pain
  • No tenderness on examination
70
Q

w/u for ovarian torsion

A
  1. sonography - Disruption of normal doppler blood flow to ovary
  2. hCG
71
Q

on sonography you see
Multiple follicles rimming an enlarged ovary
“Bulls’-eye”, “whirlpool”, “snailshell”
Rounded, enlarged ovary +/- heterogeneous stroma

dx?

A

Ovarian Torsion

72
Q

tx for ovarian torsion

A
  1. Surgery - laparoscopy or laparotomy
    - Cystectomy at surgery or after
    - necrotic - oophorectomy
  2. post-op monitoring - f, leukocytosis, peritonitis
  3. mgmt similar during pregnancy
    - progestational support If ovary removed prior to 10 weeks,
73
Q

MC source of ovarian cancer?

A

Epithelial ovarian cells - >90% of all malignant ovarian tumors

74
Q

ovarian CA typically occur in pts near or at what stage of their menstrual cycle?

A

menopause

75
Q

MC carcinoma of ovarian CA?

A

75% - serous cystadenocarcinomas

76
Q

ovarian CA is associated with what serum marker?

A

CA-125

77
Q

other causes/tumors of ovarian CA?

A
  1. Germ cell tumors - present in 20s-30s
  2. Sex Cord-Stromal Tumors - 5-8%
  3. 5% of ovarian cancers - due to metastases
78
Q

which tumor has a Better prognosis than EOC cancers
30-40% - dysgerminomas
Associated with AFP, hCG, LDH

A

Germ cell tumors

79
Q

positive RF for ovarian CA

A
  1. Positive family hx
    - Strongest risk - 10-15% of pts
  2. Increased age
  3. Caucasians
  4. smoking
  5. GYN-related
    - Early menarche (< 12 yrs)
    - Late menopause (> 50 yrs)
    - Endometriosis
    - Nulligravidity
  6. Possible - obesity, talcum powder use
80
Q

negative RF of ovarian CA?

A
  1. Oral contraceptive pill use
    - Longer duration - more protective
    - Reduced to half by 15 years of use
  2. Breastfeeding
  3. Progesterone therapy
  4. Tubal ligation
  5. Hysterectomy/Salpingectomy
81
Q

lifetime risk of ovarian cancer?

%

A

1.7%

82
Q

which BRCA is MC for ovarian cancer?

Breast-Ovarian Cancer Syndrome

A

BRCA1

83
Q

Breast-Ovarian Cancer Syndrome MC affects what pt demographic?

A

MC in women of Ashkenazi Jewish, French Canadian, Icelandic descent

84
Q

Hereditary Nonpolyposis Colorectal Cancer syndrome not only has a risk for ovarian CA but what other CAs?

A

higher risk of colon, breast, endometrial CA

85
Q

possible tx for women with any known genetic predisposition for CA?

A

prophylactic bilateral salpingo-oophorectomy
Better to do by age 35 if possible

86
Q

s/s of early ovarian CA?

A

poorly defined or vague symptoms

  • GI - bloating, abdominopelvic pain, early satiety, indigestion
  • GU - urinary frequency or urgency, dyspareunia
  • Other - fatigue, back pain
  • does not prompt pt to seek help
87
Q

s/s of late ovarian CA?

A

70% of cases

  • Early sx + inc abdominal girth (ascites), nausea, anorexia, dyspnea (pleural effusions)
  • 15% of reproductive-age patients - menstrual abnormalities
88
Q

solid, fixed, irregular adnexal mass
Unilateral cystic masses are benign in 95% of cases
Abdominal distention, upper abdominal mass, ascites
LAD - inguinal, Sister Mary Joseph’s nodule

dx?

A

ovarian CA

Metastatic disease to the skin is rare but possible

89
Q

w/u for ovarian CA?

A
  1. CA-125
  2. Younger pts - serum AFP, LDH, hCG
  3. HE4 - similar sensitivity to CA-125; Approved for monitoring ovarian CA but not screening
  4. Other markers - CEA, CA 19-9, apolipoprotein A - not specific
  5. Panel tests - OVA1, Overa
  6. Algorithms - ROMA, RMI, ADNEX
  7. abnml hormone levels
  8. pelvic US - Limited in making definitive dx
  9. CT/MRI
  10. Dx: BX and tissue pathology
90
Q

elevated CA-125 can be seen in what other conditions?

A

endometriosis, leiomyoma, PID, cirrhosis

rare for healthy women to have elevated CA-125

91
Q

what pelvic US findings would indicate cancer?

A

solid, septations, ascites

92
Q

tx for EOC cancers?

A
  1. Surgery - Required unless pt status cannot tolerate surgery
    - Definitive dx and staging
    - Removal of tumor and contralateral adnexa even if grossly normal
    - + hysterectomy and infracolonic omentectomy
  2. Medical
    - chemo - 4-6 wks after surgery
93
Q

what predicts persistent EOC cancer?

A

Elevated CA-125 level

94
Q

tx for germ cell CA

A
  1. Surgery
    - dx at earlier stage > EOC
    - Removal of involved adnexa
    - May preserve normal-appearing contralateral adnexa, uterus
    - Still perform surgical staging
  2. Medical
    - MC curable
    - Chemotherapy and radiation can be helpful
95
Q

Second MC GYN malignancy
MCC of death in GYN malignancies

A

ovarian CA

96
Q

prognosis of ovarian CA

A
  1. Stage 1 EOC - 5-yr survival 83-90%
  2. Stage 4 EOC - 5-yr survival 19%
  3. Germ cell tumors better rates > EOCs
    - Dysgerminomas - 5-year survival 95%

Women's health (15 decks)

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