The ovary and its disorders Flashcards
Anatomy and function of the ovaries
ovarian carcinoma most commonly derives from germinal epithelium
oestrogen secreted by granulose cells in growing follicles and theca cells
FSH enlarge some follicles every month
- reaches 20mm and ruptures IRT mid-cycle surge of LH → oocyte release
- follicle → corpus luteum → produces P+O to support endometrium whilst awaiting fertilisation and implantation → hCG produced by trophoblasts maintain CL function and hormone production until 7-9 wks gestation when the fetoplacental unit takes over
- if no fertilisation → CL involutes, hormone levels decline → MENSTRUATION
Ovarian cyst ‘accidents’
- Rupture of ovarian cyst into peritoneal cavity (e.g. endometrioma or dermoid cyst) → intense pain
- Haemorrhage into a cyst → pain, can cause hypovolaemic shock
- Torsion of pedicle (bulky due to the cyst) → infarction of ovary and tube → severe pain → urgent surgery and detorsion required if ovary to be saves
most ovarian masses silent and detected when very large/abdominal distension/USS
acute presentation is associated with ‘accidents’
3 disorders of ovarian function
PCOS = oligomenorrhoea, hirsutism, sub-fertility. Cysts small multiple poorly developed follicles
Premature menopause = last period reached before 40 y/o
Problems of gonadal development = gonadal dysgenesis e.g. Turner’s Syndrome
Classification of ovarian tumours:
primary neoplasms = benign/malignant
→ epithelial tumours, germ cell tumours, sex cord tumours
most common in postmenopausal women, ovarian epithelium or Fallopian tube
usually ‘borderline’ malignancy (histological features, no invasion), can become malignant → surgery advised
younger women with borderline → observation following removal of cyst or affected ovary to retain fertility, recurrence 20 years later
- serous cystadenoma or adenocarcinoma
* most common malignant neoplasm, high grade (70%) or low grade (<5%) - endometrioid carcinoma
* 10% of ovarian malignancies, associated with endometrial carcinoma - clear cell carcinoma
* 10% of ovarian malignancies, poor prognosis - mucinous cystadenoma or adenocarcinoma
* can become very large, 3% ovarian malignancies - Brenner tumours
* small and benign
Classification of ovarian tumours:
primary neoplasms = benign/malignant
→ epithelial tumours, germ cell tumours, sex cord tumours
From undifferentiated primordial germ cells of gonad, 3% ovarian malignancies
- Teratoma/dermoid cyst
- common benign tumour, young premenopausal women
- commonly bilateral, seldom large, often asymptomatic
- rupture painful
- malignant form = solid teratoma, very rare
- Yolk sac tumours
* highly malignant, present in children and young women
3. Dysgerminoma
- female equivalent of seminoma
- rare
- most common ovarian malignancy in younger women
- sensitive to radiotherapy
Classification of ovarian tumours:
secondary malignancies → tumour-like conditions (cysts)
endometriotic cysts = chocolate cysts, in the ovary they are called endometriomas, rupture very painful but uncommon
functional cysts = follicular cysts/lutein cysts are persistently enlarged follicles and CL
- only found in premenopausal women
- combined pill protects against these by inhibiting ovulation
- lutein cysts cause more symptoms
- if asymptomatic → tx not required, cyst observed using serial USS
- if cyst >5cm more than 2 months → CA 125 level measured and laparascopy to remove/drain cyst
Classification of ovarian tumours:
primary neoplasms = benign/malignant
→ epithelial tumours, germ cell tumours, sex cord tumours
from stroma of gonad and account for <2% of ovarian malignancies
granulosa cell tumours = malignant, slow-growing, rare, post-menopausal women
- secrete high levels of oestrogen and inhibin → stimulation of endometrium → bleeding, endometrial hyperplasia, enomdetrial malignancy, and precocious puberty (rarely, young girls)
- serum inhibin levels used as tumour markers to monitor for recurrence
thecomas = rare, benign, secretes oestrogen a/o androgens
fibromas = rare, benign
- → Meig’s syndrome = ascites and right pleural effusion found in conjucntion with small ovarian mass, effusion is benign nd cured by removal of mass
Ovarian cancer: epidemiology, what reduces risk?
silent nature of malignancy → late presentation so widely metastatic within abdomen
10-year survival rate = 40-50%
avg. 63 y/o
OCP reduces risk
Histological types of primary ovarian malignancy: SECMO
Ovarian cancer: pathology (most common type)
95% epithelial carcinomas BUT germ cell tumours are most common in the rare event of a women under 30 y/o being affected
grade = borderline, low, high
Ovarian cancer: aetiology and RFs
benign cysts can undergo malignant change
- RFs = nulliparity, early menarche, late menopause
- Protective = pregnancy, lactation, the pill use
Familial
- ovarian carcinoma (BRCA1/BRCA1/HNPCC)
- BRCA1 50% risk
- BRCA2 associated with breast cancer
- HNPCC (Lynch Syndrome) associated with bowel and endometrial cancer
Screening for ovarian cancer
no UK national screening programme
screening for early malignant rather than pre-malignant disease
- genetic counselling with FHx of BRCA1/BRCA2
- those with mutations are offered prophylactic salpingo-oophorectomy
Ovarian cancer: clinical features
History
- vague/absent early, 70% stage 3-4 present
- abdominal distension or mass palpated by patient
- early satiety and/or loss of appetite, pelvic/abdominal pain
- urinary urgency and/or frequency
- vaginal bleeding
- ASK ABOUT breast and GI sx (metastasis)
Examination
- cachexia
- abdominal/pelvic mass (very large less likely to be malignant)
- ascites
- PALPATE BREASTS (metastasis)
Is the ovarian mass malignant?
Spread and staging for ovarian cancer
Ovarian cancer: Investigations initial detection (primary care)
CA 125 in women >50 y/o with many abdominal sx’s
- raised (>35 IU/mL) → USS of abdopelvis
- if ascites/abdopelvic mass found → refer to secondary care
REALITY = CA-125 + USS + urgent referral to GYN
Ovarian cancer: Establishing the diagnosis (secondary care)
CA-125 + USS if not already arranged
CT abdopelvis (+thorax if clinically indicated) to establish extent of disease
- further staging usually performed using surgery
<40 y/o = AFP + hCG
RMI (risk of malignancy index) = U x M X CA125
- U is USS score, 1 point for each = multilocular cysts, solid areas, metastases, ascites, bilateral lesions
- U = 1 for score of 1 point
- U = 3 for score of 2-5 points
- M is menopausal status
- M = 1 premenopausal
- M = 3 postmenopausal
- RMI >250 refer to specialist MDT
Management of ovarian cancer (mx guide)
Palliative care: NSAID/pain ladder
Co-analgesics = antidepressants, steroids, cytotoxic
opioid analgesia can be patient controlled + anti-emetics
alternative therapies = acupuncture, behavioural techniques
Palliative care: N+V
causes = opiates, metabolic causes (e.g. uraemia), vagal stimulation (e.g. bowel distension), psychological cfactors
tx = antiemetics → anticholinergics, anti-histamines, dopamine antagonists or 5HT-3 antagonists (e.g. ondansetron)
Palliative care: heavy vagina bleeding
tx = high dose progestogens, radiotherapy
Palliative care: ascites and bowel obstruction
drain ascites by repeated paracentesis
obstruction managed at home
- partial = metoclopramide (pro-motility and anti-emetic), stool softeners, enemies for constipation, trial of dexamethasone to reduce tissue oedema
- complete = cyclizine + ondansetron for N+V, hyoscine for spasm
- eat and rink small amounts
- surgical = stents inserted in sigmoid colon or rectum
Palliative care: terminal distress
anxiolytics and analgesics
Classifications of ovarian tumours at a glance
Classifications of ovarian tumours at a glance
Carcinoma of the ovary at a glance
Ovarian cysts: types
Complex (i.e. multi-loculated) ovarian cysts should be biopsied to exclude malignancy.
ovarian cyst rupture
An ovarian cyst is most likely to rupture during physical activity (e.g. sexual intercourse, exercise).
Clinical features
- Symptoms range from asymptomatic, acute unilateral pain, to intra-peritoneal haemorrhage with haemodynamic compromise.
Differentials
- Differentials include ovarian torsion and ectopic pregnancy are other causes of acute onset of unilateral pain. Gastrointestinal causes such as appendicitis should also be considered.
Investigations
- TVUS for ovarian pathology
- Investigations involve a pregnancy test to exclude ectopic. Diagnostic laparoscopy may be needed in an unstable patient.
Management
- Management is mostly conservative, but in extreme cases surgery is needed.
Premature ovarian failure
Premature ovarian failure is defined as the onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years. It occurs in around 1 in 100 women.
TO MAKE DIAGNOSIS = hormones need to be elevated when tested TWICE, FOUR weeks apart
Causes of premature menopause include:
- idiopathic
- the most common cause
- there may be a family history
- bilateral oophorectomy
- having a hysterectomy with preservation of the ovaries has also been shown to advance the age of menopause
- radiotherapy
- chemotherapy
- infection: e.g. mumps
- autoimmune disorders
- resistant ovary syndrome: due to FSH receptor abnormalities
Features are similar to those of the normal climacteric but the actual presenting problem may differ
- climacteric symptoms: hot flushes, night sweats
- infertility
- secondary amenorrhoea
- raised FSH, LH levels
- e.g. FSH > 40 iu/l
- low oestradiol
- e.g. < 100 pmol/l
Mx:
The patient should be treated with hormone replacement therapy (HRT) until at least the age of normal menopause (51), unless the risks of HRT treatment outweigh the benefits.
