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Womens health > Ovaries > Flashcards

Ovaries Flashcards

1
Q

PCOS rotterdam criteria

A
  1. > 20 cysts on an ovary seen on US
  2. Clinical or biochemical hyperandrogenism
  3. oligo/amenorrhea (anovulation)
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2
Q

PCOS pathophysiology

A

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

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3
Q

PCOS SX

A

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

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4
Q

PCOS DDX

A

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)

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5
Q

PCOS IX

A

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

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6
Q

PCOS MX

A

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%

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7
Q

Ovarian Carcinoma

A

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)

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8
Q

Ovarian Carcinoma SX

A

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

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9
Q

Ovarian Cancer IX

A

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

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10
Q

ovarian CA Diagnosis

A

surgical, ascites tap, biopsy

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11
Q

Ovarian CA stages and prognosis

A
  1. within the ovary (90%)
  2. within the pelvis
  3. retroperitoneal or outside pelvis (40%)
  4. outside peritoneum (20%)
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12
Q

Ovarian CA MX

A

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

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13
Q

Functional ovarian cysts

A

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

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14
Q

Functional ovarian cyst IX

A

pelvic US -> adnexal mass, fluid in pelvis
BHCG

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15
Q

pre-menstural syndrome definition

A

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

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16
Q

PMS

A

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

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17
Q

PMS diagnosis

A

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

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18
Q

PMS MX

A
  • 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

19
Q

PMD

A

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

20
Q

PMD

A
  • 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
21
Q

Ovarian torsion

A

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

22
Q

Ovarian torsion SX

A
  • 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

23
Q

torsion DDX

A

ectopic pregnancy: BHCG
kidney stone -> urine dipstick -> microscopic hematuria

24
Q

torsion EX

A
  • Vitals (shock)
    • Abdominal tenderness, peritonism
    • Bimanual for adnexal tenderness, palpable masses, absence does not exclude DX
25
Q

torsion IX

A
  • 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

Baseline bloods prior to surgery
- FBE, UEC, LFT, G+H

26
Q

MX of torsion

A

surgical -> confirm torsion -> detort
determine viability of ovary
- preserve in pre menopausal
- Salpingo-oophorectomy considered in post menopausal women

27
Q

torsion CX

A

ovarian necrosis
peritonism
pelvic adhesions
hemorrhage
necrotic ovary -> infection -> abscess -> sepsis

28
Q

Functional Ovarian cysts

A

Follicular

Corpus luteal

Theca luteal

mostly in pre-menopausal women, most are benign

in postmenopausal women -> RMI -> GYN/ONC referral

29
Q

Follicular cyst

A

Most common ovarian cysts
result of anovulatory cycle
filled with straw colored fluid

30
Q

Corpus luteal cyst

A

CL fails to involute and continues to enlarge

Complex cyst features
likely to rupture
pink hemorrhagic cyst filled with blood clots

31
Q

Theca Lutein cyst

A

Associated with GTD/multiple pregnancies
High BHCG

32
Q

ovarian cyst presentation

A

Asymptomatic

Torsion

Rupture -> Sudden Iliac pain, N/V
- triggered by exercise, intercourse, mid cycle (ovulation)

33
Q

MX of functional ovarian cyst

A

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

34
Q

non functional ovarian cysts/Benign

A

Germ cell: Teratoma/dermoid cyst

Cystadenoma: Serous + Mucinous

Sex cord stromal
- Meig’s syndrome + fibromas
- Thecoma
- Sertoli leydig tumor

Endometrioma

35
Q

Malignant Ovarian tumor

A

Germ cell
- yolk sac -> increased AFP
- Choriocarcinoma - >increased BHCG

Epithelial
- Serous
- mucinous

Dysgerminoma

36
Q

Cystic teratoma/dermoid cysts

A

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)

37
Q

Dysgerminoma

A

young girls, produce LDH due to high cell turnover
malignant

38
Q

cystadenoma

A

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”

39
Q

Thecoma

A

hormonally active, makes estrogen, older ladies (perimenopause)

40
Q

Sertoli leydig tumor

A

Makes androgens, frank virilization, young patient

41
Q

Endosalpingiosis

A

Cysts formed outside the uterus

42
Q

Fibroma

A

Meig’s syndrome = Benign ovarian tumor (fibroma) + ascites + pleural effusion

SX resolve after resection of tumor

43
Q

Endometrioma

A

due to endometriosis
chocolate cyst (old blood and endometrial tissue)
rupture or torsion are common

44
Q

Granulosa Cell tumor

A

Makes estrogen and Inhibin, high AMH association

Womens health (8 decks)

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