Ovaries Disorders Flashcards
What conditions are Polycystic Ovarian Syndrome associated with?
Hirsutism Obesity Glucose intolerance/Diabetes mellitus Cardiovascular disease Metabolic syndrome Dyslipidemia NAFLD Obstructive sleep apnea
What is the Pathophysiology or reasoning behind Polysystic Ovarian Syndrome?
- . Abnormal androgen and estrogen metabolism
- Control of androgen production is unregulated
- Insulin resistance and hyperinsulinemia
- Decreased adiponectin
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How does Insulin resistance and Hyperinsulinemia cause POS?
Increased insulin alters gonadotropin effects on ovarian function
Increased insulin decreases synthesis of sex hormone binding globulin and insulin-like growth factor
What role does adiponectin do?
This is decreased in POS
Regulates lipid metabolism and glucose levels
Insulin sensitizer
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Clinical Presentation of Polycystic Ovarian Syndrome?
Infertility PCOS is most common cause Oligomenorrhea/Amenorrhea Anovulation Obesity Acne Hirsutism Upper lip, chin Male-pattern baldness Acanthosis nigricans
What is the Diagnostic Criteria for Polycystic Ovarian Syndrome?
Rotterdam Criteria 2003
Two of the three below must be present after the exclusion of related disorders
- Ovulatory dysfunction (amenorrhea)
- Clinical or biochemical signs of hyperandrogenism
- Polycystic ovaries
Which imaging would you used to diagnose POS?
What findings do you associate it with?
Ultrasound
-Presence of >12 follicles in either ovary measuring 2-9mm in diameter (Rotterdam Criteria)
-“String of pearls” appearance
Ovarian volume >10mL
-No evidence of dominant follicle / corpus luteum
To evaluate Hyperandrogenism what value must you first start to measure?
Elevated testosterone
If elevated continue to work up
What labs do you continue to order is you suspect Hyperandrogenism?
17 – OH progesterone
Measure at 8AM
> 200 ng/dL suspect CAH
DHEA-S
> 700mcg/dL suspect adrenal source for hyperandrogenism
Cortisol
> 10mcg/dL suspect Cushing syndrome
Prolactin
Normal is PCOS
> 25 ng/dL is elevated
TSH
Hyperthyroidism can cause oligomenorrhea/amenorrhea
β HCG
Order if oligomenorrhea/amenorrheaWhat additional tests do you order for POS?
Fasting glucose
OGTT or HA1c
Lipid profile
Treatments Polycystic Ovarian Syndrome?
- Weight Loss
- Meformin
Combination oral contraceptives - Fertiliy consultation
- Provera
- Life-long lifestyle mod.
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How would you treat Hisuitism?
1st Line: COC’s
-Add on therapy –> spirinolactone
- Topical elfonithine (Vaniga)
- Add on therapy Antiprotozoal
- Hair removal
Risks for POS?
Endometrial Hyperplasia/Carcinoma Type II diabetes Hypertension Hyperlipidemia Cardiovascular disease Stroke Infertility Metabolic syndrome Sleep apnea
What are PEARLS Evaluation of Adnexal Masses
Pre-menarchal
Ovaries should not be palpable
Reproductive
Palpable about 50% of the time
Peri-menopausal
Increased likelihood of residual functional cysts
Post-menopausal
Non-palpalpable within 3 years of the onset of natural menopause (most)
What imaging do you do for scanning adnexal mases?
Ultrasound
An Adnexal Mass is considered benign if ultrasound shows what?
What about Malignant
- Thin walled
- < 3cm premenopausal or < 1cm postmenopausal
- Hyperechoic nodule with distal acoustic shadowing
- Network of linear or curvilinear pattern
- Homogenous echos
Malignant if:
- Solid, nodular or papillary
- Blood flow to solid component
- Thick septations >2mm
What are the 3 types of Functional Ovarian cysts
- Follicular cysts
- Corpus Luteum Cyts
- Theca Lutein Cysts
Most common type of Benign ovarian cysts
Follicular cysts
How do Follicular cysts occur
Failure of the mature follicle to rupture (release the ovum) –> causes pain and pressure
Failure of the non-dominant follicles to undergo atresia in the presence of the mature follicle
How do Corpus Luteum cysts appear?
Following ovulation, blood accumulates within the cavity of the corpus luteum which stimulates resorption. If resorption doesn’t occur and the corpus luteum is greater than 3cm it is considered a cyst
If corpus luteum continues to persist without popping what can happen
Prolonged menstrual cycle due to continued progesterone secretions from the CL
What is the least common Benign ovarian cysts?
Theca Lutein Cysts
What is the etiology behind Theca Lutein Cysts?
How does it present
Seen with elevated chorionic gonadotropin levels
Presents:
Bilaterally
Fluid is clear, straw colored
Cysts regress spontaneously with treatment of underlying disorder
Most common nonfunctional epithelial cell ovarian tumor?
Treatment?
Serous cystadenoma
Mostly benign
Surgery:
Cystectomy vs oophorectomy
2nd most common nonfunctional epithelial cell ovarian tumor?
How does it present?
Treatment
Mucinous cystadenoma
Present:
Ultrasound= multilocular septations
Treatment: Surgery
Benign cystic teratomas are considered what type of tumors
What are these composed of?
Germ cell Ovarian Tumors
Any part of the three germ layers
- Ectoderm
- Mesoderm
- Endoderm
What is the histology behind Germ cells ovarian tumors?
Germ cell ovarian tumors originate from which type of tumors?
The cyst is lined with keratinized squamous epithelium with abundant sebaceous and apocrine glands
Hair, teeth
How do Germ cell teratomas present?
- Asymptomatic
- Pelvic pain
- Urinary frequency or urgency
- Back pain
Physical Exam findings for Germ Cell Ovarian tumors?
Imagine used?
Labs tested?
PE: Pelvic mass on bimanual exam
Imagine
Tranvaginal Ultrasound- unilateral, complex cysts
Labs:
CEA, CA-125, AFP, βHCG
-All should be within normal limits
Treatment for Germ Cell Ovarian Tumors
Surgery
Laprotomy
Ovarian cystectomy
What are the two types of Stromal Ovarian Tumors?
Who are they common in?
What do they secrete?
Granulose Theca cell tumors
- Females
- Produce estrogens
Sertoli-Leydig cell tumors
- Males
- Produce androgens
How do Ovarian Fibromas occur?
Result from spindle cell collagen production
Risk factors for Ovarian Cancer
Family history of breast, ovarian or colorectal cancer
BRCA1 and BRCA2
- Nullparity (never pregnant = more ovulations)
- Early menarche
- Late menopause
- Infertility (+/- treatment
Diets high in sat fat or animal fats
What are risk reductions for ovarian cancer?
-Multiparty
Breastfeeding
-Long-term oral contraceptive use
-At least 5yrs of use reduces the relative risk of developing ovarian cancer by 50% compared to non-users
-Bilateral tubal ligation
-Low fat diet
-Bilateral salpingectomyWhat are the 4 types of Ovarian cancers?
Epithelial
Germ Cell
Sex cord and strromal
Neoplasms metastatic to ovary
Ovarian Cancer Pathophysiology:
What is the Incessant Ovulation theory
Repeated ovarian epithelial trauma by follicular rupture and subsequent epithelial repair results in invagination of surface epithelium into the ovarian cortex creating cortical inclusion cysts
Constant epithelial “repair” leads to malignant transformation
Ovarian Cancer Pathophysiology:
What is the Fallopian tube theory
p53 is a tumor suppressor gene
Mutant p53 creates a “p53 signature”
Signature is located at the distal fallopian tube
-Location of epithelial stem cells
What are the types of Epithelial Neoplasms?
Where do they arise
- High grade serous carcinomas (70-80%)
- arise from fallopian tube
- Enodmetroid carcinomas
- arise from the ovary
- Clear cell carcinomas
- arise from ovaries
- Mucinous carcinomas
- arise from ovaries
What are the 4 types of Germ Cell ovarian cancers?
Dysgerminoma
Endodermal sinus
Immature teratoma
Mixed
Embryonal tumors
Etiology behind Germ cell ovarian cancers?
What age group is this most common in?
Highest incidence in women 20-30 years old
Etiology unknown
Most common type of Germ cell ovarian tumors?
How does it present and What does it secrete
Dysgerminomas
Present unilaterally 85-90%
Secrete lactate dehydrogenas, some produce hCG
How do Endodermal Sinus Tumors (rare) present?
What do they secrete?
Bilateral
Produce alpha fetoprotein
Most common symptoms of Ovarian cancers?
- Abdominal bloating
- Abdominal/pelvic pain
- Decreased energy or lethargy
- Early satiety
- Urinary urgency
What are some acute symptoms that occur in Ovarian cancers
Pleural effusions
Bowel obstructions
What are Physical Exam findings ovarian cancers
Ascites
Inguinal lymphadenopathy
Pelvic mass
What imaging used to detect ovarian cancers
Transabdominal / vaginal ultrasound Mammogram/Colonoscopy CT MRI CXR
What labs are used to detect ovarian cancers
- CA-125 elevated- Suspected epithelial ovarian cancer
2. Elevated hCG, AFP, LDH- Suspected germ cell tumor
Treatment for Epithelial ovarian cancers?
Consult gynecologic oncologists
Treatment for Germ cell ovarian cancers
Consult gynecologic oncologists
