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Year 4 OBGYN > Ovarian Pathology > Flashcards

Ovarian Pathology Flashcards

1
Q

Define Infertility

A

Inability of a couple to conceive after one year of regular unprotected sex

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2
Q

What percentage of couples conceive within their first year of trying?

A

84%

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3
Q

Name four risk factors for infertility

A

Increased Age
Extremes of weight
PCOS
Smoking

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4
Q

Describe some female causes for infertility

A

Tubal - PID, Endometriosis

Obstruction - Polyps, Fibroids, Adhesions

Reduced ovulation - PCOS, Pathological menopause, Thyroid pathology

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5
Q

Describe two male causes for infertility

A

Sterilisation

Reduced sperm count

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6
Q

State the normal parameters for sperm analysis

A

Ejaculation Volume : >1.5ml

pH >7.2

Sperm count per ejaculation: Around 39 million

Motility >40%

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7
Q

What initial investigations would be done to test infertility?

A

After an initial history and examining risk factors

Mid cycle Progesterone for female (21 day)

Sperm analysis

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8
Q

If there is an abnormality in the sperm analysis, when should it be re reviewed?

A

3 months

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9
Q

How can you test Tubal Patency?

A

Hysterosalpingogram

Day 5-12

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10
Q

How can you test for follicular presence in infertility?

A

Transpelvic USS on day 2/3

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11
Q

How could you estimate the response to IVF therapy using investigations?

A

Anti MH - High

FSH - low

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12
Q

How could you treat infertility if the cause was An/Oligovilation?

A

Clomiphene Citrate or Letrozole

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13
Q

How can you treat Infertility if the issue is structural?

A

Mild - surgical correction

Severe - IVF

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14
Q

How can you treat infertility if the problem is the Male?

A

Mild - Intrauterine Insemination

Severe - IVF or Sperm Donor

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15
Q

Describe the 5 step process of IVF

A

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)

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16
Q

Define PCOS

A

Polycystic Ovarian Syndrome

Common Endocrine disorder characterised by excess androgen and immature follicles in ovaries

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17
Q

Describe the pathophysiology of PCOS

A

Excess LH

Insulin Resistance (results in more insulin being produced, reducing SHBG therefore there are higher free circulating androgens - supress LH surge)

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18
Q

Give two risk factors for PCOS

A

Family History

Pre - existing diabetes

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19
Q

State 5 clinical features of PCOS

A 
Oligo/Amenorrhoea
Infertility
Hirsutism
Obesity
Acne
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20
Q

Describe the Rotterdam criteria for PCOS

A

1) Oligo/Anovulation
2) Clinical/Biochemical signs of Hyperandrogenism
3) Atleast 12 follicles on ovaries upon imaging

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21
Q

How is Anovulation managed in PCOS?

A

Aim to induce at least 3 bleeds a year

COCP

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22
Q

How is Hirsutism managed in PCOS?

A

Cyproterone Acetate

Or

Spironolactone

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23
Q

How is Obesity managed in PCOS?

A

Weight loss encouraged, Atleast to BMI <30

Last resort - Orlistat

24
Q

Name three features on examination of PCOS

A

Hirsutism
Acne
Acanthosis Nigricans

25
Q

How is Infertility in PCOS managed?

A

1) Letrozole
2) Clomiphene Citrate

+/- Metformin

26
Q

Describe the biochemical imbalance in PCOS

A

Raised : LH (at least 3:1 to FSH), Testosterone

Low: Progesterone, SHBG

27
Q

Ovarian cysts are derived from surface irritation (ie multiple ovulation). Give two risk factors and two protective

A

RF: Nulliparous, Late Menopause
Protective: COCP, Breast Feeding

28
Q

What is the Risk of Malignancy Index?

A

U x M x Ca125

U = USS features
M = Menopause status

If >250 then malignancy is very likely

29
Q

Describe the USS features scoring in RMI for Ovarian Cancer

A

Bilateral
Solid areas
Metastases
Ascites

30
Q

How do Ovarian Tumours present?

A

Chronic Pain (may be cyclical, or dyspareunia)

Compression (Increased Urinary Frequency and Constipation)

Non specific weight loss, fatigue and change in bowel habits

31
Q

What does Acute Pain in Ovarian Pathology suggest?

A

Ovarian Torsion
Cyst Rupture
Bleeding into cyst

32
Q

State the three broad categories of Ovarian Cysts

A

Physiological
Benign Germ Cell
Benign Epithelial

33
Q

Describe the two types of physiological Ovarian Cyst

A

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

34
Q

Name two benign germ cell cysts

A

Mature Cystic Teratomas (most common in under 30s, normally asymptomatic)

Monodermal (normally thyroid)

35
Q

Name three benign epithelial cysts

A

Serous Cystadenoma (mimics the most common malignant type)

Mucinous (rare, can cause pseudomyxoma peritonei if ruptured)

Brenner Tumour

36
Q

Name the four main types of Malignant Ovarian Tumours

A

Surface (ie Epithelial)
Germ Cell
Sex Cord
Metastatic

37
Q

Name three subtypes of Epithelial Malignant Ovarian Tumours

A

Serous Cystadenocarcinoma (Psammoma Bodies)

Mucinous Adenocarcinoma (Mucin secreting)

Endometrioid (appears like endometrial tissue)

38
Q

Name three subtypes of Germ Cell Malignant Ovarian Tumours

A

Immature Teratoma

Dysgerminoma (associated with Turner Syndrome, secretes LDH and hCG)

Choricarcinoma (form of GTD, secretes hCG, metastasises to lung early)

39
Q

Name three subtypes of Sex Cord Ovarian Tumours

A

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)

40
Q

How are Ovarian Cysts/Tumours managed in premenopausal women?

A

Risk stratification

hCG/LDH/AFP

Rescan in 6 weeks

If still present - laparoscopic cystectomy

41
Q

How are Ovarian Cysts/Tumours with an RMI<25 managed?

A

Follow up for 1 year with USS and Ca125

42
Q

How are Ovarian Cysts/Tumours with an RMI 25-250 managed?

A

Bilateral oophorectomy

43
Q

How are Ovarian Cysts/Tumours with an RMI >250 managed?

A

Bilateral Oophorectomy
Staging
If malignant - platinum chemo and 5y follow up

44
Q

What is OHSS

A

Ovarian Hyperstimulation Syndrome

A complication of ovulation induction/superovulation (more common with hCG/GnRH therapies than Clomiphene)

45
Q

Describe the pathophysiology of OHSS

A

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

46
Q

Name three risk factors for OHSS

A

Young
Low BMI
Previous OHSS

47
Q

OHSS can be classified into mild, moderate, severe and critical. How does Mild present?

A

Abdominal Pain and Bloating

48
Q

OHSS can be classified into mild, moderate, severe and critical. How does Moderate present?

A

Nausea and vomiting

Ultrasound evidence of ascites

49
Q

OHSS can be classified into mild, moderate, severe and critical. How does Severe present?

A

Clinical ascites
Oliguria
Raised Haematocrit

50
Q

OHSS can be classified into mild, moderate, severe and critical. How does Critical present?

A

ARDS

VTE

51
Q

How is OHSS managed?

A

VTE prohylaxis

Symptomatic relief

52
Q

Define Ovarian Torsion

A

Twisting of ovary and Fallopian tubes on its vascular and ligamentous supports, blocking adequate blood flow

53
Q

Give three risk factors for Ovarian Torsion

A

Ovarian Mass
OHSS
Pregnancy

54
Q

How would Ovarian Torsion present?

A

Abdominal Pain
Nausea and Vomiting
Peritoneal Signs

55
Q

Name four investigations for Ovarian torsion

A

FBC
Pregnancy Test
Abdominal USS (whirlpool sign)
Transvaginal USS

56
Q

How is Ovarian Torsion managed?

A

Laparoscopy is diagnostic and therapeutic

57
Q

Describe the management for infertility in PCOS

A

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

Year 4 OBGYN (15 decks)

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