ovarian disorders Flashcards
what are the types of functional ovarian cysts?
follicular and corpus luteal cysts
what are follicular cysts?
occur when follicles fail to rupture and continue to grow
what are corpus luteal cysts?
fail to degenerate after ovulation
what is theca lutein?
excess BHCG causes hyperplasia of the interna cells
when are functional ovarian cysts mc?
reproductive years
s/sx of functional ovarian cysts?
+usually unilateral
+most are self-limiting and reslove w. in a few wks
+mostly asx unless they rupture (RLQ and LLQ ppain)
+may see abnormal uterine bleeding
-painful sex
PE of ovarian cysts?
Unilateral pelvic pain/tenderness
May have mobile, palpable cystic adnexal mass
dx of functional ovarian cysts
Pelvic US
Follicular → Smooth, thin-walled unilocular
Luteal → Complex, thicker-walled with peripheral vascularity
β-hCG levels → To rule out pregnancy
tx of ovarian cysts?
supportive
if less than 8 cm will most likely spontaneously resolve
if > 8 cm or persist, or found post menopauses, can be removed
ovarian cancers
2 cd MC gyn after endometrial
*highest mortality of all gyn ca
rf for ovarian ca
Family Hx → 7% lifetime risk (Normal 1-2%)
↑# of ovulatory cycles → Infertility, Nulliparity, >50 yrs, late menopause
BRCA1/BRCA2 → 15-40%
Peutz-Jeghers or Turner’s Syndrome
40-60 yo
protective factors in ovarian ca
OCPs → Decreases # of ovulatory cycles
High parity or TAH
s/sx of ovarian ca
Abdominal fullness/distension, +back or abdominal pain, early satiety
+Urinary frequency
+Irregular menses, menorrhagia, +postmenopausal bleeding, +constipation → intestinal compression
PE of ovarian cancer/ where can it mets?
Palpable abdominal or ovarian mass → Solid, fixed, irregular + ascites
Sister Mary Joseph’s Node → METS to the umbilical lymph node
dx of ovarian ca
Biopsy → 90% Epithelial → Seen especially postmenopausal → Germ cell seen in pts <30 yrs
Transvaginal US → Useful screening in high-risk pts
Mammography to look for primary in breast
tx of early stage ovarian ca
AH-BSO + Selective Lymphadenectomy
what levels are used to monitor ovarian cysts?
Serum CA-125
what chemo can be used for ovarina ca?
Paclitaxel + Cisplatin or Carboplatin
what is the MC benign ovarian neoplasm?
DERMOID CYSTIC TERATOMA
what are most ovarian neoplasms considered in reproductive age?
benign
how are benign ovarian neoplasms tx?
Removal due to potential risk of torsion or malignant transformation
PCOS PP?
associated with abnormal function of hypothalamus-pituitary-ovarian axis → ↑INSULIN & ↑LH-DRIVEN ↑IN OVARIAN ANDROGEN PRODUCTION
*insulin resistance
what is a rf for PCOS?
obesity
what is the triad of sx for PCOS?
Amenorrhea → Chronic Anovulation
Obesity
Hirsutism → Androgen Excess
s/sx of PCOS?
Menstrual Irregularity → Secondary amenorrhea (50%), oligomenorrhea (70%)
Increased Androgen → Hirsutism (50%) - Coarse hair growth on midline structures (face, neck, abd), acne, + male pattern baldness
Insulin Resistance → Type II DM, Obesity (80%), Hypertension
PE of PCOS pt?
Bilateral enlarged, smooth, mobile ovaries on bimanual exam
Acanthosis Nigricans
Cysts are immature follicles w/arrested development due to abnormal ovarian fxn
dx of PCOS?
Exclude other disorders → Thyroid (TSH), Pituitary Adenoma (Prolactin Levels), Ovarian Tumors, Cushing’s Syndrome (Dexamethasone Suppression Test)
what labs should you order if suspecting PCOS?
↑testosterone, ↑DHEA-S (Intermediate of Testosterone),
LH:FSH ratio>3:1
(Normal 1.5:1)
lipid panel,
what specific lab test can you do for PCOS?
GnRH Agonist Stimulation Test → Rise in Serum Hydroxyprogesterone
what characteristic signs are seen on US with PCOS?
string of pearls
Bilateral enlarged ovaries with peripheral cysts
what complications can occur with PCOS?
Chronic Anovulation → ↑Risk for infertility, ↑endometrial hyperplasia & endometrial carcinoma due to unopposed estrogen
Insulin Resistance → ↑Risk of atherosclerosis & HTN
what may been seen in a pt with PCOS as they progress through maturity?
usually have normal puberty and adolescence, followed by progressively longer episodes of amenorrhea
tx of PCOS (mainstay)
combo OCP
lifestyle change,
surgery can be done to restore ovulation in pts who want kids but clomiphene doesn’t work
how does estrogen help in PCOS?
stimulates hepatic production of sex-hormone binding globulin → reducing androgen levels
how does progesterone help in PCOS?
Progesterone decreases action of testosterone at target organs by receptor antagonism
what OCP should you avoid in PCOS?
androgenic progesterone → Norgestrel and Levonorgestrel
what can be used to tx hirsutism?
Spironolactone → Structurally similar to testosterone but blocks testosterone receptors
Spironolactone = Teratogenic → Must be used with OCPs
May be added if sxs persist after OCPs
Leuprolide & Finasteride → Other Anti-Androgenics
how can infertility in the PCOS pt be tx?
Clomiphene
how does clomiphene work?
Selective Estrogen Receptor Modulator → Gonadotropin re-establishes ovulation in anovulatory women who with to get pregnant
how can metformin help in a PCOS pt?
with abnormal LH:FSH ratios may improve menstrual frequency by reducing insulin
common side effects of clomiphene?
hot flashes, pelvic pain
*increased risk of twins
which population is most at risk for ovarian torsion and why?
prepubertal girls
Based on the abdominal location of the ovary and the long utero-ovarian ligament the adnexa
s/sx of ovarian torsion
bdominal pain & ovarian enlargement on the same side demonstrated by sonography
*pretty vague sx
dx of ovarian torsion?
Doppler flow studies may further contribute to the diagnosis but even in presence of flow the ovarian vessels should not preclude the clinical impression
tx of ovarian torsion?
operative laparoscopy
what is a leiomyoma?
Benign uterus smooth muscle tumor → Most common benign gynecologic lesion
what is the growth of a leiomyoma related to?
ESTROGEN PRODUCTION → Regresses after menopause
If it grows after menopause think other causes
what population is most likely to be affected by leiomyomas?
30s (especially > 35y) → 5x more common in African Americans
what are the 4 types of leiomyomas?
Intramural, Submucosal, Subserosal, Parasitic
s/sx of leiomyomas?
Most are asymptomatic
Bleeding most common presentation → Menorrhagia, Dysmenorrhea
Abdominal pressure/pain related to size of tumors & location
Bladder → Frequency, urgency
what are PE findings for leiomyomas?
Large, irregular hard palpable mass in the abdomen or pelvis during bimanual exam
dx of leiomyomas?
elvic US → Focal heterogeneous masses with shadowing → Also used to observe for growth
tx of leiomyomas?
Observation → Majority don’t need treatment → Decision to treat is determined by symptoms, size/rate of tumor growth & the desire for fertility
medical tx of leiomyomas?
*think estrogen inhibitor–> decreased endometiral growth
what specific med can be used for leiomyomas?
leuprolide
or progestins like medroxyprogesterone (causes endometrial atrophy, shrink uterus temporarily)
MOA of leuprolide?
GnRH agonist that causes GnRH inhibition when given continuously → Shrinks the uterus temporarily until natural menopause
*only used if near menopause or preoperatively → Prior to hysterectomy
surgical tx of leiomyomas?
Hysterectomy → Definitive treatment → Fibroids = Most common cause for hysterectomy
Myomectomy → Used especially to preserve fertility
Endometrial ablation, artery embolization → Both may affect ability to conceive
what is adenomyosis?
Islands of endometrial tissue within the myometrium → muscular layer of uterine wall
PP of adenomyosis?
ectopic endometrial tissue induces hypertrophy & hyperplasia of the surrounding myometrium → Diffusely enlarged uterus
when does adenomyosis MC present?
later in the reproductive years
s/sx of adenomyosis?
Menorrhagia → Progressively worsens
Dysmenorrhea
+ Infertility
PE findings of adenomyosis?
TENDER, SYMMETRICALLY/uniformly
enlarged “BOGGY UTERUS” → “Globular enlargement”
dx of adenomyosis?
Dx of exclusion of secondary amenorrhea → Rule out pregnancy first
MRI
what is the definitive dx of adenomyosis?
Post-total hysterectomy examination of uterus
what is the only effective tx of adenomyosis?
Total abdominal hysterectomy
what are some conservative tx of adenomyosis?
sed to preserve fertility
Analgesics
Low dose OCPs
mifepristone, GnRH agonist
what is the classic adenomyosis pt?
middle aged and parous w/ sever secondary dysmenorrhea and menorrhagia and symmetrically enlarged uterus
Leiomyoma vs adenomyosis: asymmetric?
leiomyoma
L vs A: symmetric?
adenomyosis
L vs A: firm uterus?
LEIOMYOMA
L vs A: soft uterus?
adenomyosis
L vs A: tender uterus?
adenomyosis
L vs A: nontender uterus?
adenoomyosis
