Ovarian Pathology Flashcards
Define Infertility
Inability of a couple to conceive after one year of regular unprotected sex
What percentage of couples conceive within their first year of trying?
84%
Name four risk factors for infertility
Increased Age
Extremes of weight
PCOS
Smoking
Describe some female causes for infertility
Tubal - PID, Endometriosis
Obstruction - Polyps, Fibroids, Adhesions
Reduced ovulation - PCOS, Pathological menopause, Thyroid pathology
Describe two male causes for infertility
Sterilisation
Reduced sperm count
State the normal parameters for sperm analysis
Ejaculation Volume : >1.5ml
pH >7.2
Sperm count per ejaculation: Around 39 million
Motility >40%
What initial investigations would be done to test infertility?
After an initial history and examining risk factors
Mid cycle Progesterone for female (21 day)
Sperm analysis
If there is an abnormality in the sperm analysis, when should it be re reviewed?
3 months
How can you test Tubal Patency?
Hysterosalpingogram
Day 5-12
How can you test for follicular presence in infertility?
Transpelvic USS on day 2/3
How could you estimate the response to IVF therapy using investigations?
Anti MH - High
FSH - low
How could you treat infertility if the cause was An/Oligovilation?
Clomiphene Citrate or Letrozole
How can you treat Infertility if the issue is structural?
Mild - surgical correction
Severe - IVF
How can you treat infertility if the problem is the Male?
Mild - Intrauterine Insemination
Severe - IVF or Sperm Donor
Describe the 5 step process of IVF
1) GnRH subcut for 5-10d to increase FSH
2) Once three follicles seen on USS, bHCG given and 36h later they’re harvested
3) Artificial Insemination
4) 3 days later at 6-8 cell stage, analysed
5) Implanted (may use Laproscopic drilling to enhance implantation)
Define PCOS
Polycystic Ovarian Syndrome
Common Endocrine disorder characterised by excess androgen and immature follicles in ovaries
Describe the pathophysiology of PCOS
Excess LH
Insulin Resistance (results in more insulin being produced, reducing SHBG therefore there are higher free circulating androgens - supress LH surge)
Give two risk factors for PCOS
Family History
Pre - existing diabetes
State 5 clinical features of PCOS
Oligo/Amenorrhoea Infertility Hirsutism Obesity Acne
Describe the Rotterdam criteria for PCOS
1) Oligo/Anovulation
2) Clinical/Biochemical signs of Hyperandrogenism
3) Atleast 12 follicles on ovaries upon imaging
How is Anovulation managed in PCOS?
Aim to induce at least 3 bleeds a year
COCP
How is Hirsutism managed in PCOS?
Cyproterone Acetate
Or
Spironolactone
How is Obesity managed in PCOS?
Weight loss encouraged, Atleast to BMI <30
Last resort - Orlistat
Name three features on examination of PCOS
Hirsutism
Acne
Acanthosis Nigricans
How is Infertility in PCOS managed?
1) Letrozole
2) Clomiphene Citrate
+/- Metformin
Describe the biochemical imbalance in PCOS
Raised : LH (at least 3:1 to FSH), Testosterone
Low: Progesterone, SHBG
Ovarian cysts are derived from surface irritation (ie multiple ovulation). Give two risk factors and two protective
RF: Nulliparous, Late Menopause
Protective: COCP, Breast Feeding
What is the Risk of Malignancy Index?
U x M x Ca125
U = USS features M = Menopause status
If >250 then malignancy is very likely
Describe the USS features scoring in RMI for Ovarian Cancer
Bilateral
Solid areas
Metastases
Ascites
How do Ovarian Tumours present?
Chronic Pain (may be cyclical, or dyspareunia)
Compression (Increased Urinary Frequency and Constipation)
Non specific weight loss, fatigue and change in bowel habits
What does Acute Pain in Ovarian Pathology suggest?
Ovarian Torsion
Cyst Rupture
Bleeding into cyst
State the three broad categories of Ovarian Cysts
Physiological
Benign Germ Cell
Benign Epithelial
Describe the two types of physiological Ovarian Cyst
Follicular - when dominant follicle fails to atrophy, <3cm, seen in first half of menstrual cycle
Luteal - when corpus luteum fails to regress day becomes filled with fluid, <5cm, seen in second half of cycle
Name two benign germ cell cysts
Mature Cystic Teratomas (most common in under 30s, normally asymptomatic)
Monodermal (normally thyroid)
Name three benign epithelial cysts
Serous Cystadenoma (mimics the most common malignant type)
Mucinous (rare, can cause pseudomyxoma peritonei if ruptured)
Brenner Tumour
Name the four main types of Malignant Ovarian Tumours
Surface (ie Epithelial)
Germ Cell
Sex Cord
Metastatic
Name three subtypes of Epithelial Malignant Ovarian Tumours
Serous Cystadenocarcinoma (Psammoma Bodies)
Mucinous Adenocarcinoma (Mucin secreting)
Endometrioid (appears like endometrial tissue)
Name three subtypes of Germ Cell Malignant Ovarian Tumours
Immature Teratoma
Dysgerminoma (associated with Turner Syndrome, secretes LDH and hCG)
Choricarcinoma (form of GTD, secretes hCG, metastasises to lung early)
Name three subtypes of Sex Cord Ovarian Tumours
Granulosa (secretes oestrogen so can cause precocious puberty or hyperplasia in adults)
Sertoli and Leydig (secrete androgens, benign)
Fibroma (a cause of Meig’s - Pleural Effusion, Ascites)
How are Ovarian Cysts/Tumours managed in premenopausal women?
Risk stratification
hCG/LDH/AFP
Rescan in 6 weeks
If still present - laparoscopic cystectomy
How are Ovarian Cysts/Tumours with an RMI<25 managed?
Follow up for 1 year with USS and Ca125
How are Ovarian Cysts/Tumours with an RMI 25-250 managed?
Bilateral oophorectomy
How are Ovarian Cysts/Tumours with an RMI >250 managed?
Bilateral Oophorectomy
Staging
If malignant - platinum chemo and 5y follow up
What is OHSS
Ovarian Hyperstimulation Syndrome
A complication of ovulation induction/superovulation (more common with hCG/GnRH therapies than Clomiphene)
Describe the pathophysiology of OHSS
Ovarian Enlargement
Fluid shifts from Intra vascular to extra vascular (secondary to rise in oestrogen/progesterone/VEGF)
Causes pleural effusions/ascites and raked haematocrit/hypercoagulability
Name three risk factors for OHSS
Young
Low BMI
Previous OHSS
OHSS can be classified into mild, moderate, severe and critical. How does Mild present?
Abdominal Pain and Bloating
OHSS can be classified into mild, moderate, severe and critical. How does Moderate present?
Nausea and vomiting
Ultrasound evidence of ascites
OHSS can be classified into mild, moderate, severe and critical. How does Severe present?
Clinical ascites
Oliguria
Raised Haematocrit
OHSS can be classified into mild, moderate, severe and critical. How does Critical present?
ARDS
VTE
How is OHSS managed?
VTE prohylaxis
Symptomatic relief
Define Ovarian Torsion
Twisting of ovary and Fallopian tubes on its vascular and ligamentous supports, blocking adequate blood flow
Give three risk factors for Ovarian Torsion
Ovarian Mass
OHSS
Pregnancy
How would Ovarian Torsion present?
Abdominal Pain
Nausea and Vomiting
Peritoneal Signs
Name four investigations for Ovarian torsion
FBC
Pregnancy Test
Abdominal USS (whirlpool sign)
Transvaginal USS
How is Ovarian Torsion managed?
Laparoscopy is diagnostic and therapeutic
Describe the management for infertility in PCOS
1) Clomiphene
2) Clomiphene and Metformin
Clomiphene should be given on day 2-6 of cycle, for maximum 6 months
If obese then metformin alone
