B8.024 Cystic Ovaries Flashcards by Lauren Sinik

ddx of RLQ pain with negative Bhcg

acute appendicitis
gastroenteritis
diverticulitis or perf
crohns, UC
ileus
ovarian cyst
tubo-ovarian abscess

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acute appendicitis

pain around the umbilicus progressing to right lower abdomen
vomiting
fever
tachycardia

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gastroenteritis

diarrhea
vomiting
abdominal pain
lack of energy
dehydration

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diverticulitis/perf

abdominal pain
nausea
vomiting
fever
bloating or gas
constipation

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crohn’s or UC

abdominal pain
cramping
diarrhea
+/- blood in stool, fever, chills, fatigue, dehydration

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ileus

abdominal discomfort
loss of appetite
feeling of fullness
constipation
inability to pass gas
bloating
excessive belching
nausea/vomiting

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typical ovarian cyst symptoms

lower abdomen pain, fullness or heaviness
bloating/swelling
severe pain before or after menstruation
dyspareunia

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tubo-ovarian abscess

fever

chandelier sign

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types of of ovarian cysts

functional cyst (follicular, corpus luteal)
mucinous cystadenoma
mature teratoma
cancer
endometrioma

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what is an ovarian cyst

solid or fluid filled sac or pocket within or on the surface of an ovary

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ovarian cyst epidemiology

common in all age groups

most common among repro aged women
> 3 mil per year

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how are ovarian cysts diagnosed

transvaginal pelvic US

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majority of ovarian cysts symptoms

physiologic

asymptomatic

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follicular ovarian cysts

follicle fails to rupture

often resolves spontaneously

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corpus luteum ovarian cyst

CL fails to regress
may produce progesterone
may be hemorrhagic

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hemorrhagic ovarian cyst

blood filled follicular or luteal cyst

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mucinous cystadenoma

lined by columnar epithelium
typically similar to endocervical epithelium
secrete thick gelatinous mucin

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mature teratoma

dermoid
germ cell tumor
may contain ectoderm, mesoderm, endoderm derived tissues

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endometrioid cyst

manifestation of endometriosis
endometrial tissue on ovary
chocolate cyst

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clinically important parameters provided by transvaginal ultrasound

determination of the presence or absence of relatively small masses (5-10 cm)
determination of the origin of a mass (uterine, ovarian, tubal) and whether or not it has torsed
detailed eval of internal consistency of cyst
guiding transvaginal aspiration
evaluation of endometrial or myometrial disorders related to pelvic masses

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what are you looking for on US when examining internal consistence of a cyst

presence or absence or polypoid excrescences, septations, or internal consistencies (blood, pus, serous fluid)

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appearance of mature teratoma on imaging

hyperechogenic interfaces on cystic mass

can have calcifications

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appearance of simple/follicular cyst on imaging

thin smooth wall
anechoic contents
no or only few septa
no debris

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appearance of typical endometrioma on imaging

thick wall
homogeneous low level internal echoes
occasionally wall calcifications

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appearance of hemorrhagic cyst on imaging

fishnet weave/ fine reticular pattern | sign of clotting within the cyst

appearance of mucinous cystadenoma on imaging

thin septations may demonstrate echogenic material (mucin) similar to cervical epithelium

appearance of a potentially malignant cyst on imaging

thick > 3 mm septations | complex

how to rule out a torsion when looking at a cyst

doppler imaging | "ring of fire" appearance signifies NO torsion (blood flow still present)

how does the presentation of an endometrioma differ from a functional cyst

presents with chronic pain, not usually acute onset

what does periumbilical ecchymosis result from

retroperitoneal bleeding | in context of ovarian cyst: rupture

treatment of ruptured CL syst

surgical removal exploratory laparoscopy need exogenous progesterone support after surgery to prevent miscarriage

diagnostic workup for amenorrhea with hyperandrogenism

``` thyroid problems (TSH) rare enzyme defects (CAH) excessive stress hormones (cushing) tumors excessive growth hormone (IGF-1) ```

PCOS criteria

1. polycystic ovaries 2. high androgen levels 3. irregular periods

appearance of PCOS on US

strand of pearls | 12 or more follicles seen on ovary

clinical manifestations of high androgen levels

acne hair -loss: male patterned -growth: face, chest, back

lab manifestations of high androgen levels

DHEAS | testosterone

abnormal menstrual cycles in PCOS

35 days or longer heavy bleeding problems with ovulation

PCOS causes

``` endocrine disruptors genetic differences in androgen receptor or sex hormone binding globulin (SHBG) gestational hyperglycemia in utero exposure to androgens ```

evolutionary paradox of PCOS

viability advantage | decreased fertility

treatment of PCOS acne

OTC: benzoyl peroxide, salicylic acid prescription: topical/oral antibiotics, combined oral contraceptives, topical/oral retinoids

treatment of PCOS male patterned hair loss

``` topical minoxicil (rogaine) spironolactone - androgen receptor blocker combined estrogen and progesterone ketoconazole propecia (blocks DHT) ```

treatment of PCOS male patterned hair growth (hirsutism)

``` combined oral contraceptives spironolactone (6 months) propecia flutamide metformin laser therapy vaniqua (topical, 4-8 weeks) ```

systemic health problems seen with PCOS

``` heart disease obesity diabetes mood/sleep disorders cancer liver disease infertility ```

PCOS and heart disease

``` increased risk factors: 1. metabolic syndrome 2. high cholesterol 3. high blood pressure 4. obesity 3x increased risk: -stroke -heart attack ```

diagnosis of metabolic syndrome

3/5 risk factors - BP >130/85 - waist circumference >35 in - fasting glucose >100 - HDL <50 - triglycerides >150

relationship between PCOS and metabolic syndrome

21-40% of PCOS women have metabolic syndrome | half of this group is NOT obese

cholesterol abnormalities in PCOS

low HDL high triglycerides high LDL

treatment of high cholesterol in PCOS

statin: decreases cholesterol production | low cholesterol diet/excerise

high BP in PCOS

systolic >140 diastolic >90 risk of heart disease, renal failure, stroke narrowed blood vessels from damaged lining increased pressure

treatment of high BP in PCOS

weight loss smoking cessation decreased alcohol use BP meds: HCTZ, labetolol

obesity in PCOS

5-10% weight loss may: - improve ovulation - lower male hormone levels - improve metabolic abnormalities

treatment of obesity in PCOS

diet exercise meds surgery

relationship between PCOS and diabetes

``` increased risk of developing diabetes -11.9% in PCOS females > 30 -1.4% in non-PCOS females > 30 insulin resistance prevalence -40% in PCOS females ```

assessment of glycemic control in PCOS

no recommended screening test for insulin resistance measure HbA1c 2h glucose tolerance

use of metformin in PCOS

improves body's ability to process insulin decreases androgen levels improves ovulation but does not improve chance of live birth 1-4 pills/day

risk/side effects of metformin in PCOS

lactic acidosis GI distress weight loss

mood conditions in PCOS

30% have depression | 34% have anxiety

sleep disturbances in PCOS

5x more likely to have sleep apnea - periods of not breathing with sleep - shortened sleep may lead to earlier death

PCOS and cancer

2-3x increased risk of endometrial cancer | -increased endometrial growth with anovulation

typical response to PCOS treatment

all symptoms improved after 6 months

spironolactone in PCOS

potent antagonist of androgen receptor | locks T receptors and decreases T production

B8.024 Cystic Ovaries Flashcards

(61 cards)