Ovaries Flashcards
PCOS rotterdam criteria
- > 20 cysts on an ovary seen on US
- Clinical or biochemical hyperandrogenism
- oligo/amenorrhea (anovulation)
PCOS pathophysiology
insulin resistance -> GnRH dysfunction -> increased pulasatility of GnRH -> increased LH and decreased FSH (ratio of 3:1) -> annovulation and increased androgen production. lack of FSH -> no CL -> no P produced -> normal E but unopposed -> hyperplastic endometrium and heavy periods
PCOS SX
Obesity
high LH -> androgens -> hirtuism + male pattern baldness + acne + acanthosis nigricans
low FSH -> annovulation -> irregular/no periods + subfertility/infertility
unopposed E -> heavy periods
anxiety/depression
Acne, oily skin, alopecia, BMI, speculum -> enlarged adnexa
RX: metabolic syndrome, FHX
PCOS DDX
Pregnancy, Constitutional delay, normal physiological anovulation (first 2y after menarche periods are irregular and US shows lots of cysts), hyperprolactinemia, Thyroid, CAH, andogen secreting tumor (if rapid onset or very high free testosterone consider tumor)
PCOS IX
Urine BHCG, BSL, TAG, HBA1C, E D3 normal, LH:FSH (3:1), P (low D21 low as there is no ovulation, no CL), Androgens/SHBG raised testosterone, low SHBG (first line IX if Free testosterone), AMH (high no released follicles),
TFT, Prolactin, 17hydroxprogesterone for CAH, cortisol
TVUS : * string of pearls with multiple small medium sized oocytes *
OGTT: only way to diagnose glucose intolerance
PCOS MX
lifestyle: weight loss, no smoking, check BMI, lipids, BSL, OGTT, cardiometabolic health review regularly.
hyperandrogenic
- Anti-androgen: COCP Yasmin or Diane (also helps regulates periods)
- progesterone Mini Pill or Depo
- non hormonal
- Spironolactone: need to be on contraception (teratogenic)
- Finasteride
Acne and hair -> non pharmacological (Laser, dermatologist option
amenorrhea/oligo -> COCP
infertility -> Clomiphene stimulates ovulation (if pregnancy wanted, SERM)
Cosmetic -> laser removal, COCP, anti androgen
CX
- subfertility
- CVS monitoring, body weight, quit smoking, metabolic checks every 2y
- endometrial: ensure patient has periods ever 4 years to prevent endometrial hyperplasia -> RX of CA
- Women w long standing anovulation & thickened endometrium on US should have an endometrial Bx to exclude malignancy
- Mirena provides good endometrial protection and can be used as a TX in PCOS in PT with endometrial hyperplasia.
OSA
Depression/Anxiety -> psychologist
EPI 10-20%
Ovarian Carcinoma
Transcolemic: can travel beyond peritoneal cavity, can involve pleura -> pleural effusion
peaks at age 50
second most common GYN cancer, morbid, highly lethal
most common type is epithelial
- Serous (70% of epithelial)
- Mucinous type secretes mucous into peritoneal cavity -> intestinal obstruction
- clear cell: related to renal cell CA
RX
- BRACA (10%)
- Lynch (can prophylactically bilateral salpingectomy and hysterectomy)
- endometriosis (clear cell ovarian cancer) smoking
- Protective: OCP, HRT, multiparity, breast feeding, bilateral salpingo-oophorectomy (ovaries not influenced by FHS and LH. COCP supresses cellular activity -> protective)
Ovarian Carcinoma SX
non specific -> late presentation -> poorer prognosis
- early referral is key
- I organize for you with CA urgently. I do because I know that early is better and that this is overwhelming for anyone.
- want to be here to support you in any way I can
Abdominal SX: Distended abdomen/fullness/bloating, ascites, masses
GIT: indigestion, bloating, N, early satiety
Urinary/pelvic SX
Malignancy SX: bone pain, headaches, night sweats, fatigue, fever, LOW/LOA, SOB
EX: pleural effusion, ascites, abdominal mass
Ovarian Cancer IX
Tumor Markers: CA125 (not great in premenopausal women, used mainly for tracking)
TVUS: fluid in pouch of Douglas, TAUS: fluid -> floating bowel
CT chest, AB, pelvis
CXR for pleural effusion
RMI (risk of malignancy index)
- menopausal status, US findings, serum CA125
US findings: multioculated solid areas with bilateral ascites
>200 on RMI -> high risk of ovarian CA -> GYN/Oncologist referral
ovarian CA Diagnosis
surgical, ascites tap, biopsy
Ovarian CA stages and prognosis
- within the ovary (90%)
- within the pelvis
- retroperitoneal or outside pelvis (40%)
- outside peritoneum (20%)
Ovarian CA MX
Refer to GYNE and ONC
CA tracking with CA125 and follow up
- Gold standard: radical de bulking surgery. cytoreductive surgery w maximum surgical effort followed by adjuvant chemotherapy
- Stage 4 & unfit for surgery: neoadjuvant chemo followed by interval surgery
- Chemo regimen: paclitaxel/ platinum & carboplatin in dose-dense regimen
Conservative MX
- stage 1 accurately determined, confined to ovary + wants fertility -> remove abnormal ovary, BX other ovary and peritoneal cavity, endometrial BX, LN BX
Levels alone cannot be used to Rule in or out ovarian cancer. Cannot be used as a screening test as it is commonly elevated in premenopausal women. Can also be elevated for benign disease or non-gynecological reasons. Levels can also be in the normal range for patients with invasive stage 1
Functional ovarian cysts
EPI
- mostly in premenopausal women. in post menopausal women -> cysts concerning for malignancy -> further IX
Normal physiological process of follicular genesis -> generation of cysts on the ovary
Functional ovarian cyst IX
pelvic US -> adnexal mass, fluid in pelvis
BHCG
pre-menstural syndrome definition
Collection of physical and behavioural and psychological features that happen in the second half of the cycle (luteal phase: always 14d after ovulation) and then resolve following menses
PMS
Premenstrual syndrome: (1/4women) collection of premenstrual signs that are significant enough to cause perceived inhibition of daily activities
- Key features: Sx resolve once menstruation begins, Sx are NOT present before menarche, during pregnancy or after menopause.
Thought to be caused by fluctuation of oestrogen & progesterone
High progesterone in luteal phase: breast pain, bloating, headache
Low Estrogen: hot flushes, anxiety, low mood, mood swings, depression, irritability (menopausal like)
Impact on function -> PMS. no impact -> premenstrual Symptoms
PMS diagnosis
with a sx diary spanning two cycles to show cyclical signs
+
lifestyle dysfunction for 3 consecutive cycles happening in the luteal phase
+
absence of SX for at least 1 week of cycle (not depression)
Definitive diagnosis: GnRH analogue -> halts menstrual cycle -> symptom resolution
PMS MX
- Reassurance, Education (common), Insight into Why
- Multidisciplinary approach: GP, psychologist, dietician
- Lifestyle: Diary of signs, explanation to family and friends, exercise, diet
First line MX
- lifestyle, CBT, pyridoxine (vitamin B6), Continuous COCP (containing drospiridone eg Yasmin), If severe -> SSRI (fluoxetine or Sertraline on low dose)
Second Line MX
- Estrogen patch + progesterone -> bring hormones into normal range
- Mirena
- High dose SSRI
Third line MX
- IM Goserelin (GnRH analogue) + COCP. stop and start again
Fourth line MX
- Bilateral oophorectomy
PMD
Physical and behavioural signs that cause psychosocial impact. Resolution of signs post menses is not complete and signs begin to persist
Severe form of PMS: very angry and irritable, suicidal ideation and attempts
PMD
- RX: underlying psychological condition, history of abuse, mental illness, alcoholism, severe stress
- Presentation
○ Occurs in the luteal phase (systemic estrogen is low) two weeks prior to menses
○ Majority of signs are seen in the week of menses - Required for DX
○ Occur over consecutive cycles
○ Occurs within a week of menses
○ Resolve with menstrual cycle - DSM5
○ 1 of depression, anxiety, irritation/anger, labile mood
○ Behaviour SX: increased appetite, hyper or insomnia, poor concentration, forgetfulness, cognitive difficulties
Physical SX: sleep more, eat more, poor concentration, palpitations, dizziness
- Presentation
Ovarian torsion
torsion -> ischemia -> hemorrhage + necrosis
RX: ovarian cysts/tumor
pregnancy -> CL -> mass
sudden increase in intrabdominal pressure
infertility treatment ->
ovulation induction -> cysts formation
hypestimulation of ovary -> enlargement -> torsion
FSH with IVF
Normal ovaries in young girls before menarche as they have longer infundibular ligaments
Ovarian torsion SX
- Acute onset severe/sharp unilateral pelvic/iliac fossa pain (can be colicky with tort and detort).
- Peritonitis
- N
- Vomiting +++
- Fever, tachy, hypotension (necrosis and sepsis)
- More common for right ovary to tort due to the longer right ligament
Torsion on the infundibular pelvic ligament
torsion DDX
ectopic pregnancy: BHCG
kidney stone -> urine dipstick -> microscopic hematuria
torsion EX
- Vitals (shock)
- Abdominal tenderness, peritonism
- Bimanual for adnexal tenderness, palpable masses, absence does not exclude DX
torsion IX
- BHCG
- Pelvis US (TVUS with doppler Ideal)
○ Enlarged ovary with displaced follicles (fluid not drained through vein)
○ Free fluid in abdomen
○ Cysts (cause of torsion)
○ Position: located anterior to the uterus rather than lateral
○ Whirlpool sign (twisted ovary), same for testicular torsion
○ MRI if equivocal - Doppler: decreased blood flow
- Definitive DX with laparoscopy
- Pelvis US (TVUS with doppler Ideal)
Baseline bloods prior to surgery
- FBE, UEC, LFT, G+H
MX of torsion
surgical -> confirm torsion -> detort
determine viability of ovary
- preserve in pre menopausal
- Salpingo-oophorectomy considered in post menopausal women
torsion CX
ovarian necrosis
peritonism
pelvic adhesions
hemorrhage
necrotic ovary -> infection -> abscess -> sepsis
Functional Ovarian cysts
Follicular
Corpus luteal
Theca luteal
mostly in pre-menopausal women, most are benign
in postmenopausal women -> RMI -> GYN/ONC referral
Follicular cyst
Most common ovarian cysts
result of anovulatory cycle
filled with straw colored fluid
Corpus luteal cyst
CL fails to involute and continues to enlarge
Complex cyst features
likely to rupture
pink hemorrhagic cyst filled with blood clots
Theca Lutein cyst
Associated with GTD/multiple pregnancies
High BHCG
ovarian cyst presentation
Asymptomatic
Torsion
Rupture -> Sudden Iliac pain, N/V
- triggered by exercise, intercourse, mid cycle (ovulation)
MX of functional ovarian cyst
simple ovarian cysts in premenopausal women are mx based on size
- <5cm -> self resolve
- 5-7cm -> TVUS in 3mo
complex OR persisting for 3mo OR >7cm OR symptomatic -> GYN referral
Symptomatic -> simple analgesia (ruptures)
cysts in post menopausal -> RMI >200 -> GYN referral + tumor markers
complex cysts (vascularity, internal septations, papillary projections)
calculate RMI (menopausal status x US appearance x CA125)
Surgical removal if: causes persistent pain, high risk of torsion, suspicion of ovarian cancer
non functional ovarian cysts/Benign
Germ cell: Teratoma/dermoid cyst
Cystadenoma: Serous + Mucinous
Sex cord stromal
- Meig’s syndrome + fibromas
- Thecoma
- Sertoli leydig tumor
Endometrioma
Malignant Ovarian tumor
Germ cell
- yolk sac -> increased AFP
- Choriocarcinoma - >increased BHCG
Epithelial
- Serous
- mucinous
Dysgerminoma
Cystic teratoma/dermoid cysts
most common benign neoplasia in women of reproductive age
likely to tort as they are BIG
all 3 germ layers
Can secrete Thyroxine -> hyperthyroidism
Path: rokitansky protuberance (shiny white mass that can project from wall into cysts, usually site of bone/ teeth/ hair growth)
Dysgerminoma
young girls, produce LDH due to high cell turnover
malignant
cystadenoma
benign precursor to serous and mucinous carcinoma
Serous: Most common benign epithelial tumor which bears a resemblance to the most common type of ovarian cancer (serous carcinoma)
“from fallopian tubes, smaller and uniocular”
Mucinous: becomes massive -> more SX. Rupture can cause pseudomyxoma peritonei (rare malignant Ca)
“from cervix, larger, multilocular”
Thecoma
hormonally active, makes estrogen, older ladies (perimenopause)
Sertoli leydig tumor
Makes androgens, frank virilization, young patient
Endosalpingiosis
Cysts formed outside the uterus
Fibroma
Meig’s syndrome = Benign ovarian tumor (fibroma) + ascites + pleural effusion
SX resolve after resection of tumor
Endometrioma
due to endometriosis
chocolate cyst (old blood and endometrial tissue)
rupture or torsion are common
Granulosa Cell tumor
Makes estrogen and Inhibin, high AMH association
