Ovaries Flashcards
Where do the ovaries reside in the anatomy?
Ovarian fossa - lateral pelvic wall
How is are the ovaries attached to neighbouring structures?
- To broad ligament via the mesovarium
- To pelvic side wall by the infundibulopelvic ligament
- To the uterus by the ovarian ligament
What is the blood supply to the ovaries?
Ovarian artery (from aorta)
Describe the two layers of the ovaries:
Outer cortex -
- Covered by germinal epithelium (carcinoma most often arises from here)
- Contains follicles with granulosa cells & theca cells
- Granulosa and theca cells secrete oestrogen
Inner Medulla -
- Connective tissue and blood vessels
What stimulates the growth of follicles and what prevents multiple follicles developing at once?
FSH (follicle stimulating hormone) causes growth of follicles. These new follicles secrete oestrogen which inhibits FSH
What is the follicle known as after ovulation? What makes the follicle rupture?
- Corpus luteum
- Mid-cycle surge of LH
What maintains the endometrium after ovulation?
(E) and (P) secretion from the corpus luteum for 2 weeks
What occurs if fertilisation & implantation happens?
Trophoblast of the foetus produced hCG which maintains the curpus luteum for 7-9 weeks (and therefore endometrial maintenance)
What are 3 common symptoms of ovarian pathology?
- Asymptomatic (only discovered on USS)
- Abdominal distension -> when cyst becomes very large and presses onto other organs.
- Acute painful presentation - Cyst rupture, haemorrhage into a cyst or peritoneum, torsion of pedicle
What is Polycystic ovarian syndrome?
Multiple small cysts= poorly developed follicles
What is PCOS thought to be related to?
High levels of insulin. If patient is insulin resistant (i.e. in T2DM) then they will have higher levels of insulin and thus at higher risk of PCOS.
What is PCOS usually more symptomatic?
In obese women
Give 3 features of PCOS:
- Oligomenorrhoea (infrequent menstruation)
- Hirsutism (male-pattern hair growth in females)
- Sub-fertility
What counts as premature menopause?
<40yrs
What Gonadal dysgenesis know as?
Turner syndrome (45 X0). Partially or completely missing an X chromosome.
What are the 3 main types of primary ovarian tumours?
- Epithelial tumours
- Germ cell tumours
- Sex cord tumours
In what group are epithelial tumours mainly found in?
Post menopausal women
Which tumour group are ovarian tumours most commonly found in and what are they typically called?
Epithelial -> serous adenocarcinomas. These are the most common ovarian malignancies.
Most are high-grade (70%)
What is cancer can cause the abdominal cavity to fill with gelatinous mucin secretions?
Rare. Pseudomyxoma peritonei -> Mucinous adenocarcinoma.
Usually an appendiceal primary tumour
What are the two main types of germ cell tumours?
(rare, originate from undifferentiated primordial germ cells)
- Teratoma/dermoid cyst
- Dysgerminoma
What are the features of teratoma/dermoids cysts?
- Benign tumour - premenopausal women
- May contain differentiated tissue of all cell lines
- Commonly bilateral and asymptomatic -> rupture=painful
What is the most common ovarian malignancy of young women?
Dysgerminoma - female equivalent of seminoma
What are the 3 types of sex cord tumours?
(rare, originate from the stroma of the gonad)
- Granulosa cell tumours
- Thecomas
- Fibromas
In what group are granulosa cell tumours found?
Post menopausal women.
What marker is usually monitored during granulosa cell tumours?
Inhibin
What is inhibin?
Inhibin is a protein secreted by granulosa (female) and Sertoli (male) cells in response to FSH, and its major action is the negative feedback control of pituitary FSH secretion.
Describe the mechanisms of granulosa cell tumours and 3 features:
- Secrete ^oestrogen and ^inhibin.
- Malignant
- Slow growing
3 features:
- PMB
- Endometrial malignancy
- Precocious puberty
What benign tumour secretes ^oestrogen and ^androgens?
Thecomas (sex cord tumours)
What syndrome does ovarian fibroma comprise?
Meig’s syndrome:
- Ascites
- R pleural effusion
- Ovarian fibroma
What is the Rx for Meigs syndrome?
Resolves after resection of mass
Where do ovarian mets usually derive from? What percentage of ovarian tumours does this represent? What is the prognosis like?
- Breast + GI
- 10%
- Very poor
If ovarian mets contain ‘signet ring’ cells - what types of tumour is it?
Krukenberg tumour
What is a ‘chocolate cyst’?
Endometriotic cyst (endometriomas - blood accumulation)
What are ovarian ‘functional cysts’? What can cause these?
Follicular and lutein cysts (persistently enlarged follicles & Corpora lutea). COCs - stop ovulation so at risk fo developing these cysts.
What should be checked if functional cysts are very large?
CA 125
What is the most common ovarian tumour?
Serous adenocarcinoma (95%).
Germ cell tumours (dysgerminomas) if women <35yrs
What is the overall 5yr survival rate of ovarian cancer? Why?
<50%
Late onset and usually metastatic.
What is a protective factor against ovarian cancer?
Lack of oestrogen exposure (parity, COC, lactation).
Risk factors: null parity, late menopause, early menarche.
What is the inheritance pattern of ovarian cancer?
- 5% familial
- BRCA1 and BRCA2 -> breast cancer association
- HNPCC gene mutation -> Lynch syndrome 2
What would you do if someone had a +ve FH of ovarian cancer?
Test for BRCA1/BRCA2 -> if mutated -> prophylactic salpingo-oophorectomy
What percentage of those with ovarian cancer present with stage 3/4 disease?
70%
Describe 6 possible features of ovarian cancer?
- Persistent bloating/abdominal distention
- Feeling full/early satiety/decreased appetite
- Abdominal pain
- ^ Urinary urgency and frequency
- IBS-like symptoms (new-onset)
What can be found on O/E in those with Ovarian cancer?
- Cachexia (wasting of body due to severe illness)
- Abdominal/pelvic mass or ascites
- Palpate the breast for primaries
By what means does ovarian cancer usually spread?
Direct (transcoelomic spread = spreads across body cavity)
Outline the staging of ovarian cancer:
Stage 1 - Disease is macroscopically confined to the ovaries
Stage 2 - Disease extending into pelvis (uterus, fallopian tubes)
Stage 3 - Abdominal disease +/- LN involvement
Stage 4 - Disease beyond abdomen (lung or liver parenchyma)
If a lady >50 with vague abdominal symptoms presents, what test would you do? If this was abnormal, what further investigations would you do?
CA 125
If ^ -> USS abdo + Pelvis and/or pelvic examination.
Urgent referral if +ve
What additional markers would be measure in those <40 with abnormal Ix in for suspected ovarian cancer?
AFP (alpha-fetoprotein) and hCG measured -> if abnormal suggests germ cell tumour.
What does RMI stand for and what are its components?
Risk of Malignancy Index = UMCA125
U - ultrasound
M - menopausal status
CA125 - concentration of ovarian tumour marker
What level of RMI score requires specialist referral?
RMI>250
= CT pelvis/abdo
What is the typical management of someone with ovarian cancer?
Total hysterectomy + BSO + partial omentectomy.
(depending on spread, may require: bowel resection, splenectomy, peritoneal stripping, LN removal).
Chemotherapy usually follows (if stage above 1c)
How are those post surgery/chemotherapy for ovarian cancer usually monitored?
- CA 125 levels
- CT scans
List 3 poor prognostic indicators:
- ^ age
- Poorly differentiated tumours
Poor response to tumours
What type of gynaelogical cancer causes the most deaths?
Ovarian cancer.
List the 3 most common gynae cancers:
- Uterine cancer
- Ovarian cancer (most deaths)
- Cervical cancer (most common in young women, <35yrs)
What is the definition of palliative care?
The active total care of the patient whose disease is incurable.
What are the aims of palliative care?
- Increase QoL
- Symptoms control
- Addressing social, psychosocial and spiritual needs
Outline the WHO analgesic ladder:
-NSAIDs
- Mild opioids (codeine)
- Moderate opioids (codeine ^)
- Strong opioids (morphine)
(consider behavioural techniques or alternative therapies (acupuncture etc…)
List 5 issues/symptoms which need to be addressed in palliative care:
- Pain
- Nausea and vomiting
- Heavy vaginal bleeding
- Ascites and bowel obstruction
- Terminal distress (last 24hrs memorable for family)
