Ovarian Disorders

Question 1

Ovarian Cysts

Answer 1

● A sac filled with liquid or semiliquid material
that arises in an ovary
● The vast majority are benign
● Many patients with cysts are asymptomatic

Question 2

Most ovarian cysts occur as a normal
part of the process of ovulation (egg
release) → these are called _____

Answer 2

Functional cysts

Question 3

Types of Functional cysts:

Answer 3

● Follicular cysts (most common)
● Corpus luteum (Granulosa lutein) cysts
● Theca-lutein cysts

Question 4

Follicular Cysts etiology

Answer 4

● Common in premenopausal women
● Result from failure in ovulation (midcycle occurrences)
○ Most likely due to secondary disturbances in release of pituitary
gonadotropins (lack of LH surge at midcycle or excessive FSH stimulation)
○ The fluid of the incomplete follicle is not completely resorbed
○ Hormonal stimulation causes these cysts to continue to grow
● Are uncommon after menopause

Question 5

Signs/Symptoms of follicular cysts

Answer 5

● Typically asymptomatic
● Sometimes bleeding and torsion
can occur
● Can cause aching pelvic pain,
discomfort and heaviness
● Dyspareunia
● Occasional abnormal uterine
bleeding

Question 6

Treatment of follicular cysts

Answer 6

● Most resolve spontaneously
within 60 days
● The use of OCPs is frequently
recommended to help with
establishing a normal rhythm;
however, it does not produce a
more rapid resolution compared
to waiting

Question 7

Corpus luteum (granulosa lutein) cysts

Answer 7

● Thin walled unilocular cysts
● Develop from the corpus luteum
● Range from 3-11 cm in size
● Following normal ovulation, the
granulosa cells lining the follicle
become luteinized

Question 8

How do corpus luteum cysts develop?

Answer 8

Abnormal changes in the follicle
of the ovary after an egg has
been released can cause the
egg’s escape opening to seal off.
Fluid accumulates inside the
follicle, and a corpus luteum
cyst develops. -Mayo Clinic

Question 9

Signs/symptoms of Corpus luteum cysts

Answer 9

● Local pain or tenderness
● Amenorrhea
● Delayed menstruation - thus simulating the clinical
picture of an ectopic pregnancy!
● May be associated with ovarian torsion - causing severe
pain
● May rupture, causing acute pain and possibly massive blood loss

Question 10

Treating corpus luteum cysts

Answer 10

● Laparoscopy or laparotomy = if rupture occurs (ACUTE situation)
● Otherwise, symptomatic treatment is indicated
● Usually regresses after 1-2 months in menstruating patients
● OCPs have been recommended; however, they have questionable benefit

Question 11

Theca lutein cysts

Answer 11

Caused by luteinization and
hypertrophy of the theca interna cell
layer in response to excessive
stimulation from human chorionic
gonadotropin (hCG)

Question 12

These cysts are predisposed to torsion,
hemorrhage, and rupture

Answer 12

Theca lutein cysts

Question 13

Theca lutein cysts are seen in patients with

Answer 13

● Multiple gestation
● Hyperstimulation of the ovary with ovulation drugs (i.e. Clomid)
● Gestational Trophoblastic Disease (a rare condition associated with
uncontrolled proliferation of cells in the womb)
○ Hydatidiform Mole - non-viable fertilized egg implants
○ Choriocarcinoma

Question 14

These cysts are Usually seen bilaterally, filled with clear, straw-colored fluid

Answer 14

Theca lutein cysts

Question 15

Theca lutein cysts signs/symptoms

Answer 15

● Minimal
● Sense of pelvic heaviness or
aching
● Rupture may result in
intraperitoneal bleeding
● Continuing signs/symptoms of
pregnancy, esp hyperemesis,
breast paresthesias

Question 16

Theca lutein cyst treatment

Answer 16

● Signs/symptoms will disappear
spontaneously following termination of the molar pregnancy, treatment of choriocarcinoma, or discontinuing of fertility therapy - may take months to occur
● Surgery is reserved for complications such as torsion or hemorrhage

Question 17

Endometriomas

Answer 17

● A type of blood-filled cyst formed
when uterine endometrial tissue
grows on the ovaries
○ Associated with endometriosis

Question 18

Also referred to as “chocolate cysts”

Answer 18

Endometriomas

Question 19

Endometriomas treatment

Answer 19

Relief of symptoms (eg, pain or mass), prevent complications (eg, rupture or torsion), exclude malignancy, improve subfertility, and preserve ovarian function
Treatment Options:
● Surgical resection
● Observation with serial imaging

Question 20

Teratoma

Answer 20

● A form of a germ cell tumor that contain elements from all three embryonic
germ layers: ectoderm, endoderm, and mesoderm
○ May contain hair, muscle bone
● Usually occur in the ovaries,
testicles, or spinal cord
● May be benign or malignant

Question 21

Ovarian Torsion

Answer 21

The twisting of the ovary or
both the ovary and fallopian
tube

Question 22

S/S of ovarian torsion

Answer 22

● Acute, severe
abdominal and pelvic pain
● Sometimes
nausea/vomiting

Question 23

Risk Factors for ovarian torsion

Answer 23

● Pregnancy
● Induction of ovulation
● Ovarian enlargement
● Hx of pelvic surgery

Question 24

Ovarian Torsion diagnosis

Answer 24

● Ultrasound (usually see
adnexal mass and reduced
blood flow on Doppler)

Question 25

Management of ovarian torsion

Answer 25

● If reproductive age and mass is benign →
untwist, remove mass, stabilize ovary with
sutures
● If tissue is nonviable or necrotic,
salpingo-oophorectomy is required
● Recurrence rate - 19%

Question 26

Polycystic Ovarian Syndrome (PCOS)

Answer 26

PCOS is a clinical syndrome characterized by mild obesity, irregular menses or
amenorrhea, and signs of androgen excess (eg, hirsutism, acne)

Question 27

PCOS pathophysiology

Answer 27

● The syndrome involves anovulation or
ovulatory dysfunction and androgen
excess of unclear etiology
● One of the most common causes of
amenorrhea.
● In the US, it is the most common cause of infertility.
● Most common cause of ovulatory dysfunction in reproductive-age women

Question 28

Two of the three must be present for a
diagnosis of PCOS:

Answer 28

1. Oligo- and/or anovulation
2. Signs of hyperandrogenism
   a. Hirsutism (50%), infertility, weight
   gain (30-75%), acne, irregular
   menstrual cycle
3. Polycystic ovaries

Question 29

PCOS S/S

Answer 29

● Mild obesity
● Slight hirsutism
● Irregular menses or amenorrhea
● Acne
● Temporal hair thinning
● Weight gain
● Fatigue
● Low energy
● Mood swings
● Depression/anxiety

Question 30

Also called
“oyster ovaries”

Answer 30

PCOS
Ovaries are enlarged and “sclerocystic”
with smooth, pearl-white surfaces
without indentations

Question 31

Pathophysiology of PCOS

Answer 31

MOA - exact cause unknown
Many small follicular cysts accumulate because none of them are capable of growing
to a size to stimulate ovulation
Insulin resistance and hyperinsulinemia play a role

Question 32

Treatment goals of PCOS

Answer 32

● Correct hormonal abnormalities and reduce risk of estrogen excess and
androgen excess
● Relieve symptoms and improve fertility

Question 33

Polycystic Ovarian Syndrome (PCOS) treatment

Answer 33

● OCPs - not desiring pregnancy
● Infertility treatment for those desiring pregnancy: Clomiphene citrate (Clomid)
● Insulin-sensitizing agents alone or
in combination to induce ovulation
a. Metformin
b. Rosiglitazone

Question 34

Complications of PCOS

Answer 34

● Estrogen levels are elevated, increasing risk of endometrial hyperplasia and
eventually endometrial cancer
● Androgen levels are often elevated, increasing the risk of metabolic
syndrome and causing hirsutism.

Question 35

Also known as “Primary Ovarian Insufficiency”

Answer 35

Premature Ovarian Failure

Question 36

The ovaries stop functioning normally in women <____ years

Answer 36

40
○ Stop releasing eggs or release them only intermittently
○ Stop producing the hormones estrogen, progesterone, and testosterone
or produce them only intermittently

Question 37

Etiology of Premature ovarian failure

Answer 37

● Insufficient number of follicles present at birth
● Rate of follicular atresia is accelerated (damaged ovaries - surgery, chemo/rad)
● Follicles are dysfunctional (autoimmune ovarian dysfunction)
● Certain genetic disorders are present (Turner syndrome, Fragile X)

Question 38

Diagnosis of premature ovarial failure

Answer 38

● FSH and estradiol levels (high
and low, respectively)
● Pregnancy test (urine hCG)
● Thyroid function tests
● Sometimes genetic testing

Question 39

Treatment of premature ovarian failure

Answer 39

● Oral contraceptives
● Estrogen/progestogen therapy
○ Hormone therapy is to be taken
until about age 51
○ Maintains bone density and
relieves symptoms and
complications of estrogen
deficiency