Ovarian Disorders

Question 1

What are the most common hormonal abnormalities in PCOS?

Answer 1

Excess LH –> stimulates ovarian production of androgens

Insulin resistance –> surpasses hepatic production of sex hormone binding globulin

Question 2

What is the diagnostic criteria for PCOS?

Answer 2

2 out of 3 of the following:

• oligo and/or anovulation
• clinical or biochemical signs of hyperandrogenism
• polycystic ovaries on imaging

Question 3

Which blood tests should be done to investigate PCOS and what will they show?

Answer 3

Testosterone - high
SHBG - low
LH - raised
FSH - normal
Progesterone - low

Question 4

How is oligo/amenorrhoea managed in PCOS?

Answer 4

COCP
Dydrogesterone if pill contraindicated

(protects endometrial lining)

Question 5

How is infertility treated in PCOS?

Answer 5

Clomifene +/- metformin to induce ovulation

Laparoscopic ovarian drilling in women with normal BMI

Question 6

What are the risk factors for ovarian cancer?

Answer 6

Nulliparity
Early menarche/late menopause
Oestrogen only HRT
Smoking
Obesity
BRCA 1 + 2
Lynch syndrome

Question 7

Which factors are protective against ovarian cancer?

Answer 7

Multiparity
COCP
Breastfeeding

Question 8

Which tool is used to risk stratify suspected ovarian cancer and what are the components?

Answer 8

Risk of Malignancy Index (RMI):
M = menopausal status
U = ultrasound score
CA125 = cancer antigen 125 blood test

RMI = M x U x CA125

Question 9

How is menopausal status graded in the RMI?

Answer 9

1 = premenopausal
3 = postmenopausal

Question 10

How is ultrasound score graded in the RMI?

Answer 10

Features:

• multilocular cyst
• solid areas
• metastases
• ascites
• bilateral lesions

No features = 0
1 features = 1
2 or more features = 3

Question 11

How is the RMI interpreted?

Answer 11

RMI > 250 should be referred to gynae oncology

Question 12

How might ovarian cancer present?

Answer 12

Incidental + asymptomatic (scanning for other reason)
Chronic pain
Acute pain e.g. bleeding, rupture or torsion
Vaginal bleeding

Question 13

Which symptoms should be specifically enquired about to detect ovarian cancer?

Answer 13

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

Question 14

What are the different types of ovarian tumours?

Answer 14

Epithelial:

• serous
• mucinous
• endometrioid
• clear cell

Sex cord/stromal (rarer):

• granulosa cell
• thecoma/fibroma
• sertoli/leydig cell

Germ cell:

• teratoma
• dysgerminoma
• endodermal sinus or yolk sac
• choriocarcinoma

Metastases:

• endometrial
• breast
• pancreas
• GI

Question 15

Which type of ovarian cancer is most common?

Answer 15

Serous tumours

Question 16

What are the features of a teratoma?

Answer 16

Usually benign
If mature, may contain hair, teeth etc
If malignant (rare) produce HCG, AFP or thyroxine

Question 17

Where does ovarian cancer tend to spread?

Answer 17

Peritoneal cavity

Para-aortic nodes

Question 18

Which system is used to stage ovarian cancer?

Answer 18

FIGO system

Question 19

What are the different stages of ovarian cancer?

Answer 19

1A - limited to one ovary
1B - limited to both ovaries
1C - involves surface of ovary/tumour in spill/washings
2A - uterus/fallopian tubes
2B - other pelvic/intraperitoneal
3A - retroperitoneal lymph node
3B - peritoneal mets beyond pelvis up to 2cm
3C - peritoneal mets > 2cm
4 - distant mets

Question 20

What is the treatment for cervical cancer?

Answer 20

Usually combination of chemotherapy + surgery
Surgery along for stage 1A/B
Chemotherapy alone for those not fit for surgery

Question 21

What is the surgery done for ovarian cancer?

Answer 21

TAH BSO + omentectomy

total abdominal hysterectomy + bilateral salpingoophrectomy

Question 22

What are the features of simple and complex ovarian cysts?

Answer 22

Simple:
- fluid only
Complex:
- irregular, can contain solid material, blood or have separations

Question 23

What are the types of functional ovarian cysts?

Answer 23

Follicular cysts

Corpus luteal cysts

Question 24

What are the features of follicular cysts?

Answer 24

Normally less than 3cm

Developing follicle in first half of menstrual cycle

Question 25

What are the features of corpus luteal cysts?

Answer 25

Normally < 5cm

Occur in luteal phase after formation of corpus luteum

Question 26

What are the types of pathological, non-neoplastic cysts?

Answer 26

Endometrioma (chocolate cysts)
Polycystic ovaries
Theca lutein cyst

Question 27

What are the features of polycystic ovaries?

Answer 27

Ovaries contain > 12 astral follicles, or ovarian volume > 10ml
Ring of pearls seen on USS

Question 28

What causes theca lutein cysts?

Answer 28

Markedly raised hCG e.g. molar pregnancy

- they regress upon resolution of the raised hCG

Question 29

What are the different types of benign ovarian cysts, that have the potential to become malignant?

Answer 29

Serous cystadenoma
Mucinous cystadenoma
Brenner tumour (solid grey or yellow appearance)
Mature cystic teratoma (dermoid cyst)
Fibroma

Question 30

Which syndrome is associate with ovarian fibromas?

Answer 30

Meig’s syndorme

- ascites/pleural effusion

Question 31

What is the management for ovarian cysts in premenopausal women?

Answer 31

Measure lactate dehydrogenase, AFP and hCG due to risk of germ cell tumours
Don’t need to measure CA125 if simple cyst on USS
Rescan in 6 weeks
- if persistent, monitor and calculate RMI
If persistent or >5cm consider cystectomy or oophorectomy

Question 32

What is the management for ovarian cysts in postmenopausal women?

Answer 32

Low RMI –> follow up for 1 year if < 5cm
Moderate RMI –> bilateral oophorectomy, if malignancy found then staging + completion of surgery
High RMI –> referral for staging laparotomy

Question 33

Which tumours are characterised by Psammoma bodies?

Answer 33

Serous cystadenocarcinomas
(most common ovarian cancer)

Question 34

How is ovarian cancer progression monitored?

Answer 34

CA125 level