The Ovary and Its Disorders. Flashcards
What are ovarian symptoms?
Ovarian masses are often silent and detected when large and cause distension, or incidentally on USS. Acute
presentation is associated with ‘accidents’.
Define ovarian cyst.
fluid filled sac in the ovarian tissue
Describe the aetiology of ovarian cysts.
- Endometrioma: cyst formed via endometrial tissue on the ovary
- Functional cysts (occur around ovulation)
- Follicular: unruptured Graffian follicle (failed rupture of dominant; failed degeneration of non- dominant)
- Luteal: following rupture, it reseals and distends with fluid
- Haemorrhagic: bleeding into a functional cyst
How common are ovarian cysts? What are the RFs?
- 8% of pre-menopausal woman have one
RF: PCOS, Obesity, early menarche, 1st trimester of pregnancy and endometriosis
How do ovarian cysts present?
- Presentation: lower abdo pain, deep dyspareunia, pressure symptoms, abdominal swelling, asymptomatic
- Acute accident: severe right/ left iliac fossa pain accompanied by vomiting in torsion. Includes:
- Torsion
- Haemorrhage
- Rupture
- Infection
How do we investigate ovarian cysts?
- Acute presentation: exclude pregnancy
- TVUSS 🡪 hyper/hypoechoic regions
- Bloods:
- FBC
- G&S
- CA-125
- bHCG, LDH, AFP 🡪 germ cell tumour
- Doppler ultrasonography
- Consider: MRI and laparoscopic investigation
- RMI should be calculated
- Ovarian torsion most likely to occur with mature cystic teratomas
- Rupture of endometriotic and dermoid cysts causes most severe symptoms
How should we manage a simple cyst?
- <50mmm 🡪 do not require follow-up, should resolve in 3 menstrual cycles
- 50-70mm 🡪 yearly USS
- 70mm+ 🡪 consider MRI or surgery
How do we manage a complex cyst?
- Complex cyst (multi-loculated):
Laparoscopy/laparotomy 🡪 discuss oophorectomy
How should we manage an acute presentation of an ovarian cyst?
- ABC approach
- Ovarian cystectomy with oophorectomy if there is any necrosis
- Broad spectrum Abx
How should we manage a Solid/persistent/growing cysts?
should always be removed
What are the complications of ovarian cysts?
Complications: cyst accident, subfertility, malignant change, oophorectomy
All ovarian cysts that are suspicious of malignancy in a postmenopausal woman, as indicated by a RMI I greater than or equal to 200, CT findings, clinical assessment or findings at laparoscopy, require a full laparotomy and staging procedure.
What is an ovarian cyst accident? How should they be managed?
- Rupture of contents of ovarian cyst into peritoneal cavity → intense pain, especially if endometrioma
or dermoid cyst - Haemorrhage into a cyst or peritoneal cavity also causes pain
- Torsion of the pedicle causes infarction of the ovary + tube with severe pain
o Urgent surgery and detorsion required
What are the disorders of ovarian function?
- PCOS: oligomenorrhoea + hirsutism + sub-fertility - Cysts = multiple, poorly developed follicles
- Premature menopause: last period before 40 years of age
- Problems of gonadal development: gonadal dysgeneses – most common = Turner’s Syndrome
How do we classify primary neoplasms?
Can be benign or malignant
Classified together as benign cyst can undergo malignant change
What are epithelial tumours? Who do they present in?
Tumour derived from epithelial layer covering the ovary (90%). Mainly postmenopausal women
How do we classify epithelial tumours?
By histology
What are the types of epithelial tumours? How do we manage them?
-
Borderline - malignant histological feature are present but not invasive
- May become malignant so surgery is advised .
- In younger women - close observation may be offered following removal of the cyst or unaffected overy to preserve fertility
- Recurrence can occur up to 20 yrs later.
-
Serous cystadenoma
(adenocarcinoma)
– most common malignant ovarian neoplasm 50% malignancies- Classed as high grade or low grade
-
Mucinous cystadenoma
(adenocarcinoma) → can become v large
– 3% of ovarian malignancies- Abdominal cavity fills with gelatinous mucin secretions
-
Pseudomyxoma peritonei
– borderline variant of
mucinous cystadenoma
→ filling of abdominal
cavity with mucinous
secretions -
Endometroid Carcinoma
– 10% of ovarian malignancies,
similar histologically to
endometrial Ca → poor prognosis - Clear cell carcinoma - malignant varinat that accounts for 10% of ovarian malignancies
-
Brenner Tumour
Rare, small, usually
benign
What are germ cell tumours and who do they present in?
Undifferentiated primordial
germ cells of gonad and present in young, premenopausal women.
What are the types of germ cell tumours? How do we manage them?
-
Teratoma (dermoid cyst)
- Common and benign
- Contains fully differentiated tissue of all cell lines (commonly hair and teeth)
- Commonly bilateral
- Asymptomatic
- Rupture = painful
- A malignant form, the solid teratoma, also occurs in this age group but v rare.
- Surgical removal
-
Yolk sac tumour
- Highly malignant and present in young women/children.
-
Dysgerminoma
- Female equivalent of seminoma
- Most common malignancy in younger women
- Sensitive to radiotherapy
Define sex cord tumours. Who does it present in?
Tumour from the stroma of the gonad (the cells that hold the ovaries together and produce female hormones). Mainly young premenopausal or post-menopausal
What are the types of sex cord tumours?
-
Granulosa cell tumour
- Rare, malignant but slow growing
- post-menopausal women
- Secrete oestrogens and inhibin
- Stimulation of endometrium → PMB, endometrial hyperplasia and precocious puberty
- Serum inhibin used as a marker
-
Thecoma
- Rare, usually benign
- Secrete androgens or oestrogens
-
Fibroma
- Rare and benign
- Meig’s Syndrome: ascites and right pleural effusion found with small ovarian mass
- Cured by removal of the mass
What are secondary malignancies?
Ovary = common site for metastases, particularly from breast and GIT
Secondaries = 10% malignant ovarian masses
Describe the epidemiology of ovarian cancer.
In the United Kingdom each year, ovarian cancer is diagnosed in over 6500 women and causes approximately 4400 deaths.
Many women present with advanced disease with little prospect of cure.
The 5 year survival rate for advanced ovarian cancer between 2005–2009 was 43%
Describe the aetiology of ovarian cancers.
- Premalignant phase not normally recognised
- Risk factors relate to number of ovulations
o Early menarche
o Late menopause
o Nulliparity - Protective
o Pregnancy
o Lactation
o COCP - OCa may be familial via BRCA1, BRCA2 and HNPCC
o Two relatives affected, lifetime risk = 13.1%
o With BRCA1: 50%
Nulliparity, fertility tx, FH, Hx of breast cancer, high fat diet, HNPCC, Lynch syndrome, early menarche/late menopause, IUD, endometriosis