Ovarian Disorders - Exam 3 Flashcards
What is the normal size for a functional ovarian cysts? Do they always have to be symptomatic?
3-10cm
NO! some do not have any symptoms
What will large/symptomatic functional ovarian cysts present like?
menstrual irregularities
pelvic pressure or pain
Large: constipation or urinary frequency
What are the symptoms of functional ovarian cysts a result of? 3 things
Rupture of contents (chemical peritonitis)
Torsion of enlarged ovaries
Mechanical pressure
How do you dx functional ovarian cysts? What is the MC type of functional ovarian cysts?
pelvic US
follicular cysts
What are follicular cysts due to?
Due to failure in ovulation, incomplete development and it does NOT rupture and the fluid does NOT get completely reabsorbed
What are the s/s of follicular cysts?
usually asymptomatic!!
but may see bleeding and torsion
large cysts: aching pelvic pain and dyspareunia
What is the tx for follicular cysts? When should the patient follow up?
observation and expectant management, can treat symptoms if needed
Usually resolve spontaneously within 2 months but need to monitor clinically and f/u with imaging for 2-3 menstrual cycles
If you are going to tx follicular cysts with something besdies expectant management, what would you choose?
OCPs: but does NOT speed up resolution of cysts
or cystectomy
What causes a corpus luteum cysts? **Associated with pts taking ______ (drug). These can sometimes mimic _____
accumulation of fluid inside a corpus luteum
clomiphene (Clomid)
s/s can sometimes mimic an ectopic pregnancy
______ s/s include asymptomatic or local pain, tenderness, amenorrhea or delayed menstruation. What can it lead to?
Corpus Luteum Cysts
May lead to ovarian torsion or cyst rupture
and bleeding
If a corpus luteum cysts ruptures, why is this a bad thing?
Severe bleeding/rupture - acute abdomen,
hypovolemic shock
What is the tx for a corpus luteum cyst? What is the tx for a more severe presentation?
management symptoms and monitor, usually resolves sponataneously within 2 months
OCPs or surgical intervention
______ is the US finding associated with corpus luteum cysts
“ring of fire” appearance
What is the cause of theca lutein cysts? Are they usually unilateral or bilateral? What are they filled with? Describe their appearance
elevated levels of hCG
Hydatidiform mole, choriocarcinoma, multiple gestation, hCG therapy
Often occur bilaterally, filled with clear fluid
May occur as multiple simultaneous cysts
What are the s/s of a theca lutein cyst?
usually minimal symptoms
May have pelvic heaviness or aching
May see rupture and bleeding or ovarian torsion
What am I?
What is the tx?
How long does it take to see a resolution?
theca lutein cysts
tx the symptoms and the underlying cause, will resolve once the hCG levels return to normal (BUT the pt WILL have symptoms!!)
May take MONTHS to resolve
_____ is needed if there is torsion of hemorrhage for a theca lutein cyst
surgical intervention
What is the underlying cause of an endometriomas? What pt population? They may develop ______. What is another name for them?
endometric foci on ovarian surface
Seen in patients with endometriosis
May develop fibrous enclosure
“chocolate cysts”
What are s/s of endometriomas? What cancer marker can be elevated?
pelvic pain, dyspareunia,
dysmenorrhea, infertility
CA-125 may be elevated
What am I?
What is the tx?
endometriomas
removed laparoscopically
_____ is an ovarian cyst that is filled with various types of tissue. Give some tissue examples
dermoid cyst
Fatty material, hair, teeth, bits of bone, cartilage
_____ of ovarian cysts in premenopausal women are dermoid cysts and arise from _____. What is important to note?
10-15%
arise from germ cells
Rarely neoplastic but may rupture
______ develop from cells on the outer surface of the ovary. Usually _____ but can grow very large and cause pain
cystadenomas
benign
What am I?
cystadenoma
What am I?
dermoid cyst
What is another name for polycystic ovarian syndrome? What is it characterized by?
Stein-Leventhal Syndrome
endocrinopathy so it is NOT isolated to just the GYN system and a complex multivariable disorder
persistent anovulation
What are some things associated with persistent anovulation that you will see in polycystic ovarian syndrome?
Enlarged polycystic ovaries
Secondary amenorrhea or oligomenorrhea
Obesity, hirsutism, infertility
How common is PCOS? What are the 2 MC symptoms?
10% prevalence
hirsute: 60-90%
obesity: 50-80%
_____ prevalence in 1st degree relatives of PCOS pts. What relationship is thought to be damaged?
20-40%
Hypothalamic-pituitary-ovarian dysfunction: with altered LH action and altered flliculogenesis
The etiology of PCOS is unclear, what 3 things may potentially contribute to the thought process?
Hypothalamic-pituitary-ovarian dysfunction: Altered LH action, altered folliculogenesis
Insulin resistance and obesity
Hyperandrogenism
diagnosis of PCOS is based on the _____ criteria. must have ___ of the following
Rotterdam Criteria
at least 2 of the
following must be present:
Oligo-ovulation (oligomenorrhea) or
anovulation (amenorrhea)
Hyperandrogenism: including male pattern hair loss or growth
Polycystic ovaries on US
Describe the ovaries of pt with PCOS
“Oyster ovaries” - enlarged and sclerocystic
ovaries; smooth, pearl-white surfaces
without indentations
How are PCOS and infertility related?
PCOS is a leading cause of female infertility
increased early pregnancy loss (30-50%) and increased pregnancy complications
What are some gynecologic symptoms of PCOS?
Menstrual abnormalities
Ovarian cysts
Pelvic pain or pressure
Endometrial neoplasia
What are some psychosocial symptoms of PCOS?
Anxiety, depression
Low self-esteem
Negative body image
Decreased quality of life
What are some constitional/endocrine symptoms of PCOS? What do you NOT tend to see?
Weight gain or obesity
Insulin resistance
Sleep apnea
NAFLD
Dyslipidemia
Metabolic syndrome
do NOT have:
NO increased muscle mass, decreased breast size, deepened voice, clitoromegaly
What are some dermatologic s/s of PCOS?
hirsutism
acne, oily skin, dandruff
male pattern hair loss
acanthosis nigricans
In hirsutism, where on the body are the pts likely to experience new hair growth? How common is it?
coarse, dark hairs in male pattern (face, chest, stomach, back)
70-80% cases - 2o PCOS
Which regards to hormone levels, what will you see in PCOS in terms of androgens, SHBG and LG/FSH ratio?
Androgens - mildly elevated
testosterone, androstenedione, DHEA
SHBG - decreased
Increased ratio of LH to FSH
What will PCOS due to a pt’s lipid panel?
Lipid abnormalities - high LDL and TG, low HDL
What will a pelvic US reveal in PCOS?
Pelvic US may reveal multiple follicles/cysts bilaterally
“ring of bubbles”
PCOS will have signs of _____ on diagnostic testing. Including what 3 things?
anovulation
Persistently high LH and low FSH
Low day-21 progesterone level
Anovulation on sonographic follicular monitoring
What am I? What dx?
“ring of bubbles”
PCOS
What is the tx for PCOS in patients with 8-12 periods a year, with MILD hyperandrogenism and do NOT wish to conceive? What do you need to confirm before proceeding?
observation with regular screening for lipids, DM and weight
Need to make sure the patient is SATISFIED with observation
What is the major lifestyle change that is beneficial in PCOS?
5-10% weight loss can restore normal ovulatory cycles in some patients
well balanced hypocaloric diet
After lifestyle changes, ____ should be considered for the treatment of PCOS
combination oral contraceptives
**Why is combination oral contraceptives preferred in PCOS? Specifically which meds?
**Induce regular menses and antagonizes endometrial proliferation
Reduce androgen levels → suppress FSH/LH release, increase SHBG
Chose COCs with progestins that have less androgenic properties: Norethindrone, norgestimate, desogestrel, drospirenone
____ needs to be order in a PCOS pt who has not had menses in more than 4 weeks
pregnancy test first!! before starting COCs
**Why is progesterone only therapy NOT preferred in PCOS? When is it used?
**Does not treat hyperandrogenic symptoms
used mainly in pts who cannot take COC and helps prevent endometrial hyperplasia
_____ is used in PCOS as an insulin sensitizing agent. Why do people use it? _____ can also be used due to SE of weight loss
metformin
May increase spontaneous ovulation induction
GLP-1 agonists
What is the important pt education point with regards to hirsutism and PCOS? What are the tx options?
many treatments require 6-12 months! this is not an overnight fix!!
COCs
GnRH agonists
depilation
epilation
androgen receptor antagonists
5-alpha-reductase inhibitors
What is the difference between depilation and epilation?
Depilation - hair removal above skin surface
Shaving, topical chemical depilatories
Epilation - removal of entire hair shaft
Mechanical, electrolysis, laser
_____ is the androgen receptor antagonists often used in combination with COCs to help with hirsutism. What may it cause? Is it safe in pregnancy?
spironolactone
may cause metrorrhagia
NOT safe in pregnancy
_______ are 5-alpha-reductase inhibitors that help to decrease testosterone conversion. Are they safe to use in pregnancy?
Finasteride, dutasteride
NOT safe to use in pregnancy
The tx aimed at managing acne in PCOS focuses on ????
involves lowering androgen levels
or you can just treat it like acne: topical retinoids, benzoyl peroxide, isotretinoin, topical or systemic antibiotics
_____ is the dietary supplement that may help improve _____. What 2 additional things may it help with?
Myo-Inositol
insulin sensitivity
may help ovulatory frequency and weight loss
________ is a new emerging therapy in PCOS that may help slow GnRH pulses in PCOS patients. Early studies showed improved ___ and ____ levels
NK3 antagonists / Kappa-receptor agonists
LH
testosterone levels
_____ is used first line in PCOS to help ovulation induction despite being off-label. When is it given? What are the DDI?
Letrozole (Femara)
Given days 3-7 of menstrual cycle to produce a larger amount of FSH
methadone/levomethadone, tamoxifen
What are the advantages of Letrozole (Femara) when compared to clomiphene citrate?
Higher rates of live birth, especially in obese women
shorter 1/2 life (48 hours vs 2 weeks with clomid)
_____ MOA inhibits aromatase, the enzyme that converts androgens to estrogens. What does this result in?
Letrozole (Femara)
Increased production of GnRH → FSH/LH
______ MOA binds to hypothalamus, blocking estrogen receptors. What does this result in?
Clomiphene citrate (Clomid)
SERM
Increased production of GnRH → FSH/LH
What are the serious SE of Clomiphene citrate (Clomid)? What is the highlighted one?
alopecia, increased risk of ovarian or endometrial cancer, ovarian hyperstimulation syndrome, uterine fibroid enlargement
What are the DDI of Clomiphene citrate (Clomid)? Clomid induces ovulation in ____, but successful pregnancy in only ____
drugs that act on HPO axis (e.g., estrogens, SERMs, aromatase inhibitors, gonadotropins, GnRH agonists)
75-80%
30-40%
_____ can be used alone or in combo with clomiphene to induce ovulation in PCOS pts
metformin
______ can be used to induce ovulation in pts with PCOS and causes ovulation in ____ and pregnancy in _____. What are the pts at high risk for?
Exogenous gonadotropins
72%
pregnancy in 45%
high risk for ovarian hyperstimulation syndrome
Why is ovarian hyperstimulation syndrome bad?
due to vascular hyperpermeability - 3rd spacing of fluid
____ Ovarian Hyperstimulation Syndrome: bloating, N/V/D, weight gain
Ovaries enlarged 5-12 cm; mild ascites
mild
______ Ovarian Hyperstimulation Syndrome:
increased weight gain (>2 lbs/d), N/V/D, dark urine, oliguria, thirst, dry skin and hair
moderate
______ Ovarian Hyperstimulation Syndrome: SOB, pleural effusion, severe oliguria, pain in the calf / chest / abdomen, hemoconcentration, thrombosis, respiratory distress
severe
What is the tx for ovarian hyperstimulation syndrome? What medication is better than _____
Supportive; resolves 1-2 wks after d/c medication
Lower incidence with Clomid than synthetic FSH
What are the 2 surgical tx options for PCOS?
Laparoscopic ovarian surgery: cauterization, laser “drilling,” biopsies
Oophorectomy
What can cauterization, laser “drilling,” biopsies as surgical tx for PCOS cause?
May induce ovulation in patients unresponsive to medical therapy
Ovarian torsion is a ______. What is the underlying cause in 50-80% of cases? What is another likely cause?
surgical emergency!!
ovarian enlargement (think cysts)
10-22% of torsion cases occur during pregnancy
What is the classic presentation of an ovarian torsion?
sudden onset, severe, unilateral, lower abd. pain
Pelvic pain
ovarian mass
N/V
fever
Over 50% on right side; may radiate to flank, thigh or groin
______ is the MC presenting symptom in ovarian torsion. _____ is also super common presenting factor
pelvic pain: 90%
ovarian mass: 86-95%
______ is the imaging study of choice in ovarian torsion. What are some specific findings? _____ should be ordered next
US with doppler that shows abnormal blood flow to ovary
Multiple follicles rimming an enlarged ovary
“Bulls’-eye”, “whirlpool”, “snailshell”
pregnancy test
What is the tx for ovarian torsion? What does a black-blue discoloration indicate?
sx!! detorsion of the adnexa
Persistent black-blue discoloration is NOT pathognomonic for necrosis
If you remove an ovary of a pregnant lady before 10 weeks, what should you do next?
If ovary removed prior to 10 weeks, progestational support given to maintain pregnancy
______ is the MC source of ovarian cancer. Accounts for ____ of all malignant ovarian tumors. When does it occur?
Epithelial ovarian cells
> 90%
Typically occur in pts near or at menopause
____ are serous cystadenocarcinomas and are associated with ____ serum marker
75%
CA-125
_____ ovarian cancer presents in their 20-30s and have a ____ prognosis than epithelial ovarian cells. What cancer markers?
Germ cell tumors
better prognosis
Associated with AFP, hCG, LDH
______ account for 5-8% of ovarian cancer and are associated with ____ and _____
Sex Cord-Stromal Tumors
estrogen and androgens
________ ovarian cancer is associated with inhibin
Granulosa cell tumors
inhibin
____% of ovarian cancers are due to metastases
5% due to metastases
_____ is the strongest risk factor for ovarian cancer
positive family hx! 10-15% of pts will have a family hx
What are the risk factors for ovarian cancer?
family hx
increased age
white
smoking
GYN: early menarche, late menopause, endometriosis, nulligravidity
What factors REDUCE the risk of ovarian cancer?
oral contraceptive pill use
breastfeeding
progesterone therapy
tubal ligation
Hysterectomy/Salpingectomy
**What is a female pt’s lifetime risk of ovarian cancer?
1.3%
Pts with the BRCA1 gene have a ____ lifetime risk for ovarian cancer. BRCA2 gene have a ___ lifetime risk of ovarian cancer
BRCA1 - 35-45%
BRCA 2 - 15-24%
pts with Hereditary Nonpolyposis Colorectal Cancer syndrome have a ___ lifetime risk of ovarian cancer
3-14%
increased risk of colon, breast and endometrial CA
can offer _____ to women with a known genetic predisposition. What age is preferred?
prophylactic bilateral salpingo-oophorectomy
Better to do by age 35 if possible
What are some s/s of late stage ovarian cancer?
increased abdominal girth (ascites)
nausea
anorexia
dyspnea (pleural effusions)
early stage ovarian cancer s/s are very non-specific: bloating, abd. pain, early satiety, indigestion, urinary frequency or urgency, dyspareunia, fatigue, back pain
What is the classic PE finding for ovarian cancer? What lymph node?
solid, fixed, irregular adnexal mass
but unilateral cystic masses are benign in 95% of cases
Lymphadenopathy - inguinal, Sister Mary Joseph’s nodule (belly button)
_____ cancer marker is elevated in ___ of early cases of ovarian cancer and ____ of late cases. Is it more helpful in pre or post menopausal women? What is the big takeaway?
CA-125
50% early and 80% late
More useful in postmenopausal
Normal CA-125 does not exclude diagnosis of cancer!
_____ is used first when dx ovarian cancer, then _____. ____ is definitive dx
pelvic US
CT or MRI
bx and tissue pathology
**What finding on pelvic US is super bad in terms of ovarian cancer dx?
omental “cake” metastases
NOT a good thing!
What is the tx for EOC ovarian cancer? elevated ____ predicts persistent disease
sx! for both definitive dx and staging
Removal of tumor and contralateral adnexa even if grossly normal, perform hysterectomy and infracolonic omentectomy
aka they are taking a TON of structures with it!!
chemo usually starting 4-6 weeks after sx
elevated CA-125 predicts persistent disease
What is the tx for germ cell ovarian cancer?
sx! including removal of involved adnexa but MAY PRESERVE normal-appearing contralateral adnexa and uterus
sx is considered curable in the majority of cases but chemo and radiation can be helpful
____ is the 2nd MC gyn malignancy but is the #1 _____. What type of ovarian cancer has the better 5 year survival rate?
ovarian cancer
MC cause of death in gyn malignancies
Germ cell tumors usually have better 5-yr survival rates than EOCs
