Ovarian Disorders

Question 1

What is polycystic ovary syndrome?

Answer 1

Common endocrine disorder characterised by excess androgen production and the presence of multiple immature follicles within the ovaries
Affects 5-10% of premenopausal women

Question 2

Describe the pathophysiology of PCOS.

Answer 2

Excess LH production due to increased GnRH pulse frequency.
This stimulates ovarian production of androgens.
Insulin resistance resulting in high level of insulin secretion.
This suppresses hepatic production of sex hormone binding globulin resulting in higher levels of free circulating androgens.
Increased androgens suppress the LH surge.
Follicles develop within the ovary, but are arrested at an early stage and remain visible as cysts in the ovary.

Question 3

What are the risk factors for PCOS?

Answer 3

Diabetes
Irregular menstruation
FH of PCOS

Question 4

What are the clinical features of PCOS?

Answer 4

Oligomenorrhoea/amenorrhoea
Infertility
Hirsutism
Obesity
Chronic pelvic pain
Depression
Acne
Acanthosis nigricans (insulin resistance)
Male pattern hairloss
HTN

Question 5

What are the differentials of PCOS?

Answer 5

Hypothyroidism (obesity, hair loss, insulin resistance)
Hyperprolactinaemia (oligomenorrhoea/amenorrhoea, acne, hirsutism)
Cushing’s Disease (obesity, acne, hypertension, insulin resistance, depression)

Question 6

What are the blood tests that need to be done for suspected PCOS and what are the expected results?

Answer 6

Testosterone (raised)
SHBG (low)
LH (raised)
FSH (normal)
Progesterone (low)
TSH (hypothyroidism)
Prolactin (hyperprolactinaemia)
Oral glucose tolerance test (due to increased risk of diabetes) - do particularly in women with BMI >30

Question 7

What is the diagnostic criteria for PCOS?

Answer 7

Rotterdam criteria
2 out of 3 criteria need to be met:
- oligo/anovulation
- clinical/biochemical signs of hyperandrogenism
- polycystic ovaries on imaging

Question 8

What imaging needs to be done in suspected PCOS? What are the typical findings?

Answer 8

Numerous peripheral ovarian follicles (cysts)

Ovarian volume >10cm^3

Question 9

What is the treatment for oligomenorrhoea/amenorrhoea in PCOS?

Answer 9

Low dose COCP/dyhydrogesterone (if COCP contraindicated)

Used to induce at least 3 bleeds a year.

Question 10

Why is it important to treat oligmenorrhoea/amenorrhoea in PCOS?

Answer 10

Anovulatory cycles - unopposed oestrogen - endometrial hyperplasia - risk of malignancy.
Need to protect the endometrium from hyperplasia.

Question 11

What is the treatment for obesity in PCOS?

Answer 11

Very important as achieving a BMI<30 may be enough to trigger a regular menstrual cycle.
Healthy lifestyle.
Severe cases - orlistat (pancreatic lipase inhibitor).

Question 12

What is the treatment for infertility in PCOS?

Answer 12

Clomifene +/- metformin
Helps induce ovulation
If normal BMI could also try laparoscopic ovarian drilling

Question 13

What are the problems associated with with clomifene/metformin use in PCOS?

Answer 13

Increased risk of multiple pregnancies/ovarian hyperstimulation syndrome/ovarian cancer.
Therefore, limited to 6 cycles.

Question 14

What is the role of metformin in PCOS?

Answer 14

Improves insulin sensitivity
Helps with menstrual disturbance an ovulatory function
Useful in women trying to conceive with BMI >25

Question 15

What is the treatment for hirsutism in PCOS?

Answer 15

Cosmetic
Anti-androgens (cyproterone, spironolactone, finasteride)
- avoid in pregnancy - teratogenic
Eflornithine - topical cream that can reduce the growth rate of facial hair

Question 16

What is an ovarian cyst? Who are they common in?

Answer 16

A fluid-filled sac within the ovary.
They are common, especially in premenopausal patients where Benin, physiological cysts predominate throughout the menstrual cycle.

Question 17

What should be done with women with small ovarian cysts?

Answer 17

Should not raise concerns unless symptomatic

Often resolution confirmed on scanning (at 12 weeks/3 menstrual cycles)

Question 18

What is the concern with ovarian masses and what tool is used to determine the likelihood of this?

Answer 18

Concern over whether the mass is malignant or not.
The risk of malignancy index (RMI) is a tool used in practice to determine the likelihood of this.
The tool allows for triage and referral to a cancer centre for treatment as indicated.

Question 19

What is the aetiology of ovarian cancer?

Answer 19

Derived from surface epithelial irritation during ovulation.
Therefore, the more ovulations that take place, the higher the chance of developing ovarian cancer.

Question 20

What are the risk factors for ovarian cancer?

Answer 20

Nulliparity
Early menarche
Late menopause
HRT containing oestrogen only
Smoking 
Obesity
Genetics (FH, BRCA1&2, hereditary nonpolyposis colorectal cancer)

Question 21

If patients have BRCA1/2 gene mutations they can opt for a prophylactic salpingo-oophorectomy. DOes this completely remove the risk of developing malignancy?

Answer 21

No.

Question 22

What are the protective factors for ovarian cancer?

Answer 22

Multiparity
COCP
Breastfeeding

Question 23

How is the risk of malignancy index calculated?

Answer 23

RMI = U x M x CA125
M (menopausal status)
- 1 pt premenopausal
- 3 pts postmenopausal
U (USS)
- 1 pt 1 feature
- 3 pts 2+ features
CA125 (cancer antigen 125 measured from a blood test - units/ml)

Question 24

What are the features on USS that might make you suspect ovarian cancer?

Answer 24

Multilocular cyst
Solid areas
Metastases
Ascites
Bilateral lesions

Question 25

What are the clinical features of ovarian cancer/cysts?

Answer 25

Incidental and asymptomatic
Chronic pain (2o to pressure on bladder/bowel causing frequency/constipation)
In those who have endometriosis and have developed chocolate cysts - may have dyspareunia/cyclical pain
Acute pain (bleeding into cyst/rupture/torsion)
PV bleeding
Nonspecific gynae/GI symptoms - presentation may be vague - delaying diagnosis

Question 26

What are important symptoms to ask about when suspecting ovarian cancer?

Answer 26

Bloating
Change in bowel habit
Change in urinary frequency
Weight loss
IBS
PV bleeding

Question 27

What should bb looked out for when examining a patient with suspected ovarian cancer?

Answer 27

Resuscitate if shocked (if cyst rupture/torsion)
Look for abdominal masses arising from the pelvis
Look for ascites
Examine the pelvis for discharge, bleeding, adnexal masses and cervical excitation

Question 28

How are ovarian tumours categorised?

Answer 28

Non-neoplastic (no malignant potential)

Neoplastic (ability to become malignant)

Question 29

What is a simple ovarian cyst?

Answer 29

One that contains fluid only

Question 30

What is a complex ovarian cyst?

Answer 30

Can be irregular/contain solid material/contain blood/have septations/have vascularity

Question 31

What is the management of ovarian cysts in premenopausal women?

Answer 31

CA125 does not need to be taken when the diagnosis of a simple ovarian cyst has been made on USS. CA125 can be raised by anything which irritates the peritoneum for which there are many benign causes in the premenopausal woman.
Lactate dehydrogenase, alphaferoprotein and hCG should be measured in all women under 40 to check for germ cell tumours.
Rescan cyst in 6 weeks - if persistent - monitor with USS and CA125 3-6 monthly and calculate RMI.
If persistent/over 5cm - consider laparoscopic cystectomy/oophorectomy.

Question 32

What is the management of ovarian cysts in postmenopausal women?

Answer 32

Low RMI (<25) - follow up for 1 year with USS and CA125 if less than 5 cm
Moderate RMI (25-250) - bilateral oophorectomy and if malignancy found then staging is required (with completion surgery of hysterectomy, omentectomy +/- lymphadenectomy)
High RMI (>250) - referral for staging laparotomy