Ovarian disorders

Question 1

PCOS is d/t

Answer 1

Chronic anovulation
Polycystic ovaries
Hyperandrogenism

assoc. w/ hirsutism, obesity, glucose intolerance/DM, metabolic, dyslipid, NAFLD

Question 2

PCOS path

Answer 2

• Abn. androgen and estrogen metabolism
• Control of androgen production is unregulated

Insulin resistance and hyperinsulinemia

Decreased adiponectin

Question 3

which hormone is more effected by PCOS? LH or FSH?

Answer 3

LH!

FSH is downregulated by estrone

Question 4

what is the role of insulin resistance and hyperinsulinemia in PCOS?

Answer 4

Incr’d insulin alters gonadotropin effects on ovarian function

Incr’d insulin decreases synthesis of sex hormone binding globulin and IGF

Question 5

what is decreased adiponectin in PCOS

Answer 5

Regulates lipid metabolism and glucose levels

Insulin sensitizer

Question 6

PCOS path

Answer 6

incr. LH –> incr. androgens

FSH production depressed

incr. androgens –> converted to estrogen via adipose tissue
incr. circulating insulin –> more androgens

Question 7

clinical presentation of PCOS

Answer 7

Infertility
Oligomenorrhea/Amenorrhea
Obesity
Acne
Hirsutism
acanthosis nigricans

Question 8

dx for PCOS

Answer 8

ovulatory dysfx (amenorrhea)
clinical/biochem signs of hyperandrogenism, polycystic ovaries

exclude: premature ovarian failure, physical stress, obesity, no hormonal contraceptives, Pituitary adenoma / hyperprolactinemia
Thyroid disorder

Question 9

U/S findings for PCOS

Answer 9

“string of pearls”

> 12 follicles measuring 2-9mm (Rotterdam criteria)

no evidence of corpus luteum

Question 10

To evaluate for hyperandrogenism, start with measuring ____ in suspected PCOS pts

Answer 10

total testosterone

Question 11

Hyperandrogenism requires:

Answer 11

17 – OH progesterone
DHEA-S
cortisol
prolactin
TSH
*beta HCG

+/- FPG, OGTT, A1c, lipids

Question 12

Tx for PCOS

Answer 12

Weight loss 
Metformin (only pt's w/hyperinsulinemia)
combo OCP's (low androgenic activity)
fertility consultation
provera 10mg QD x 10d
life-long lifestyle modification

Question 13

Hirsutism tx for PCOS

Answer 13

1st line: COCs
Add on therapy
Anti-androgen – spironolactone 50-100 mg BID
Topical eflornithine (Vaniqa) - Antiprotozoal
Mechanical hair removal

Question 14

PCOS risks

Answer 14

Endometrial Hyperplasia/Carcinoma
Type II diabetes
Hypertension
Hyperlipidemia
Cardiovascular disease
Stroke
Infertility
Metabolic syndrome
Sleep apnea

Question 15

eval of adnexal mass

Answer 15

Pre-menarchal: ovaries should not be palpable

reproductive: palp 50% of time

peri-menopausal: inr. likelihood of residual functional cysts

post-menopausal: nonpalp w/in 3 yrs of onset

Question 16

what are examples of functional ovarian cysts?

Answer 16

Follicular Cysts
Corpus Luteum Cysts
Theca Lutein Cysts

Question 17

nonfunctional ovarian neoplasm examples

Answer 17

Epithelial cell tumors
germ cell tumors
stromal cell tumors

Question 18

functional ovarian cysts path

Answer 18

One of these follicles in one of the ovaries becomes the mature follicle (Graafian follicle) and contains the ovum

at time of ovulation –> Graafian follicle ruptures and the ovum is released, now the follicle is referred to as the corpus luteum

If fertilization occurs –> corpus luteum will persist and secrete progesterone to support pregnancy

Question 19

characteristics of fx follicular ovarian cysts

Answer 19

MC
2-8cm
non-malignant
regress after 1-2 menstrual cycles

from either: failure of the mature follicle to rupture OR failure of the non-dominant follicles to undergo atresia in the presence of the mature follicle

Question 20

characteristics of corpus luteum fx ovarian cyst

Answer 20

size = 3-11cm
usu. resolves after 1-2 menstrual cycles

following ovulation, blood accumulates within the cavity of the corpus luteum which stimulates resorption. If resorption doesn’t occur –> cyst.

Question 21

Fx ovarian cyst theca lutein cyst characteristics

Answer 21

least common, B/L, clear straw colored fluid

elevated chorionic gonadotropin levels (hydatidiform mole, choriocarcionma)

tx underlying so cyst will regress

Question 22

nonfx epithelial cell ovarian tumor: serous cystadenoma characteristics

Answer 22

MC epithelial cell neoplasm

30-50y/o

70% benign

tx = surg (cystectomy vs oophorectomy)

Question 23

nonfx epithelial cell ovarian tumor: mucinous cystadenoma

Answer 23

15% malignant, can be very large

U/S findings: multilocular septations

tx = surg.

Question 24

nonfx germ cell ovarian teratoma: benign cystic teratoma

Answer 24

Represents 40-50% of benign neoplasms

Reproductive age women (median age 30)

Malignancy rate < 1%

Question 25

nonfx germ cell ovarian teratoma: patho

Answer 25

Parthenogenic Theory:
originate from primordial germ cells, found along migration pathway of germ cells from yolk sac to gonads

Composed of well-differentiated tissue derived from any of the three germ layers

Question 26

what is the MC germ layer assoc. w/teratoma?

Answer 26

ectodermal origin (hair, teeth)

• cyst lined w/abundant sebaceous and apocrine glands

Question 27

Clinical presentation of teratoma

Answer 27

Asx.

pelvic pain, urinary frequency/urgency, back pain

Question 28

teratoma PE

Answer 28

pelvic mass on bimanual exam

Question 29

lab/studies for teratoma

Answer 29

Transvaginal ultrasound

CEA, CA-125, AFP, βHCG (should all be norm)

Question 30

Tx for teratoma

Answer 30

SURGICAL

Laparotomy Vs. Laparoscopy
Ovarian cystectomy Vs. Oophorectomy
Recurrence is ~10%

Question 31

Nonfx stromal cell ovarian tumors: Granulosa theca cell tumors

Answer 31

Develop along primarily female cell type
Produce estrogens

Occur across the lifespan
Malignant potential

Question 32

nonfx stromal ovarian tumors: Sertoli-Leydig cell tumor characteristics

Answer 32

Develop along primarily male gonadal tissue type
Produce androgens

Occur across the lifespan
Malignant potential

Question 33

nonfx stromal cell ovarian teratoma: ovarian fibromas characteristics

Answer 33

Result from spindle cell collagen production
4% of ovarian tumors
Usually in middle age
No hormone production
Small, solid tumor with smooth surface

Question 34

49

Answer 34

49