Ovarian Disorders Flashcards
What are the 3 keys to Polycystic Ovarian Syndrome?
1. Chronic anovulation (increased risk of endometrial cancer) 2 Hyperandrogenism (ex. hirsuitism, acne, male-pattern baldness) 3. Polycystic ovaries
-Insulin resistance/hyperinsulinemia (ex. acanthosis nigricans)
LH stimulates ____ cells to produce androgens
Theca
What finding on US is characteristic of PCOS?
“string of pearls”
>12 follicles, 2-9mm in diameter. No dominant follicle
Because there is insulin resistance with PCOS, what drug should be considered first line?
Metformin
-also helpful for anovulation
For the androgen excess of PCOS, what medications are indicated?
OCPs (central suppresion)
Spironolactone, Finasteride (peripheral androgen blockade)
In PCOS, which hormone dominates, LH or FSH?
LH»_space;>FSH (so lack of stimulation to granulosa cells)
What effect does circulating insulin have on the ovary?
Increased insulin stimulates ovary to produce more androgens
What is the most common cause of infertility?
Polycystic ovarian Syndrome
How is the Rotterdam Criteria (2003) used to diagnose PCOS?
2 of 3 to dx
- Ovulatory dysfunction
- Clinical or biochemical signs of hyperandrogenism
- Polycystic ovaries
IF you suspect a patient has PCOS with hyperandrogenism, what is the first initial study to get?
Total testosterone*
Normal: 40-60ng/dL
Elevated: >60ng/dL, so get further labs
What do you need to rule out/exclude before trying to diagnose PCOS?
- Cushing’s Syndrome
- Hyperthyroidism
- Pituitary adenoma
If 12-OH progesterone is elevated (at 8AM), what should you suspect?
congenital adrenal hyperplasia
What is the initial treatment to recommend to someone with PCOS?
weight loss
What is 1st line treatment for hirsutism?
Combination of oral contraception with low androgenic activity
- decrease LH–>decreased Testosterone
- Increase testosterone binding capacity to lower free testosterone
Adjunct: spironolactone
What drug is used for endometrial protection in PCOS?
Provera 10mg QD
What do you need to educate the patient about regarding lifestyle modification?
it will be life long
Pre-menarchal ovaries: palpable?
no
Reproductive age ovaries: palpable?
~50% of the time
When should ovaries become non-palbale in a post-menopausal women?
within 3 years of onset
Benign US findings
- Thin walls
- Homogenous echogenicity (endometrioma)
- <3cm premenopause, or <1cm postmenopause (simple cysts)
- Hyperechoic nodule, distal acoustic shadowing (teratoma)
- Network of linear or curvillinear pattern (hemorrhagic cyst)
What are 3 ultrasound findings that would concern you for malignancy?
- thick septations
- Solid components
- Blood flow to solid component
What are the 3 types of functional ovarian cysts?
- Follicular Cysts (MC**)
- follicle isn’t resorbed, or non-dominants don’t go away - Corpus Luteum Cysts
- pt. will not have a period - theca Lutein Cysts
- elevated hCG
- associated with abnormal pregnancies (hydatidiform mole, choriocarcinoma)
- bilateral, clear straw-colored fluid
Serous cystadenoma
- MC epithelial cell neoplasm
- non functional
- 20% malignant
- Aged 30-50 years
Mucinous cystadenoma
-2nd most common epithelial cell neoplasm
-non functional
-LARGE!!
US: multilocular septations
What is the most common of all benign ovarian lesions?
Benign cystic teratoma (dermoid cyst)
40-50% of benign neoplasms
What do granulosa theca cell tumors produce?
estrogens
What do Sertoli-Leydig cell tumors produce?
androgens
Ovarian cancer: intro/general
- 2nd MC gynecologic cancer
- MC cause of gynecologic cancer death in US
Ovarian cancer: risk factors
- Increased exposure to estrogens (nullparity, early menarche, late menopause, endometriosis, obesity)
- Family history of breast, ovarian or colorectal cancer
- BRCA1/BRCA2
- Lynch Syndrome
- White race
- Turner’s Syndrome
What is the best way to reduce risk for ovarian cancer?
Bilateral salpingectomy (remove fallopian tubes)
What are the 4 major types of ovarian cancer?
- Epithelial** MC (high grade serous (MC)*, endometroid, clear cell, mucinous carcinomas)
- Germ cell (MC dysgerminoma)*
- Sex cord and stromal
- METs to ovary
What is the tumor suppressor gene associated with ovarian cancer?
p53 tumor suppresor gene
“p53 signature” is located at the distal fallopian tube*
Describe how a patient with ovarian cancer may present?
- Abdominal bloating or distention
- Abdominal/pelvic pain
- Decreased energy or lethargy
- Early satiety
- Urinary urgency
Germ cell ovarian cancer: general
- MC in women 20-30 yrs
- Unilateral
- Produce tumor markers**
IF you are suspicious a patient may have ovarian cancer, what labs or imaging would help with diagnosis?
- Elevated hCG, AFP, LDH*(suspect germ cell–> dysgerminoma)
- CA-125 elevation (suspect epithelial cancer)
Which germ cell ovarian cancer is the only one that is bilateral?
Endodermal sinus tumor
