exam 3 - adnexal disorder Flashcards
(33 cards)
incidence of ovarian cysts
Approx. 80% of women will have an ovarian cyst found on pelvic ultrasound.
importance of adnexal masses
-Common, can rupture or cause hemorrhage
-May cause ovarian torsion or be malignant
-May be painful or asymptomatic
ultrasound
-Initial study for adnexal mass
-Transvaginal preferred
-Black = fluid, White = solid, Gray = mixed
-Can assess blood flow
benign adnexal masses
-Functional cysts
-Corpus luteum cysts
-Endometriomas
-Tubo-ovarian abscesses
-Mature teratomas
nongynecologic DDx of adnexal masses
-BENGIN:
-diverticular abscess
-appendiceal abscess
-mucocele
-nerve sheath tumors
-ureteral diverticulum
-pelvic kidney
-paratubal cyst
-bladder diverticulum
-MALIGNANT:
-gastrointestinal CA- krukenburg tumor
-retroperitoneal sarcoma
-metastatic ds
A morbidly obese 30 yo G0, LMP 2 weeks ago, presents to the ED with dizziness and intermittent paresthesia of bilateral upper extremities and chest. She also reports a 50# weight gain over the past year.
She attributes the weight gain to having worked as a manager at McDonald’s for last 6 months.
On physical exam, a large abdominal mass measuring 59 cm (from superior to inferior borders) is noted.
CT scan (ordered by ED physician) shows the following, which is noted to arise from the R ovary.
Because of the finding, the ED physician requested a consult from the Gynecology service.
Dx: Mucinous cystadenoma. Managed via laparoscopic drainage and cystectomy.
functional ovarian cysts
-often found incidentally
-resolve within 6wks
-May be symptomatic, especially if rupture -> unilateral lower quadrant pain
-granulosa cells of ovarian follicle occasionally cont to function after ovulation should occur
-Granulosa cells produce estrogen -> abnormal bleeding
-cysts grow to ab 5 cm, and may fill w/ fluid
-abdominal pain, abnormal menstrual cycle
-estrogen can cause abnormal bleeding
-US -> simple cyst with no solid components or septations
-picture- benign
-Tx:
-Manage expectantly
-If ruptures -> usually only pain meds are required
-If persists -> must be re-evaluated and possibly removed
-Hormonal contraceptives often prevent formation of other cysts and may be used if desired (does not affect ones already there)
🔹 I. What Are They?
Definition: Benign, physiologic ovarian cysts that arise from the normal function of the ovary during the menstrual cycle.
Key Point: NOT a disease—just an exaggeration of normal ovulatory physiology.
🔹 II. Pathophysiology
After ovulation, the follicle should rupture and regress.
In functional cysts, granulosa cells continue to function:
They keep producing estrogen.
The cyst may fill with fluid and enlarge (up to ~5 cm).
This causes:
Unilateral lower quadrant pain (if ruptured)
Abnormal uterine bleeding (from unopposed estrogen)
Scenario Action
Asymptomatic & <5 cm Expectant – repeat US in 6 weeks
Ruptured but stable vitals Pain control only
Persistent >6 weeks or >5 cm Re-evaluate, possible removal
Recurrent cysts Consider OCPs to suppress ovulation
corpus luteum cysts
-Occur after ovulation
-Progesterone production by the theca cells may delay onset of menses
-May cause unilateral lower quadrant pain
-Often, there is a palpable and tender adnexal mass
-Must r/o ectopic gestation by obtaining UCG
-Pts generally do not have hx of current hormonal contraceptive use
-Ruptured corpus luteum cysts can cause significant hemorrhage
-May require surgery
-Otherwise, manage with analgesics (very painful)
-pic- ring of fire sign on R. due to doppler imaging
endometriomas
-Ovarian endometriosis
-May partially or completely replace normal parenchyma
-Thick-walled structures with brown fluid resembling chocolate syrup (“chocolate cysts”)
-Usually <15 cm in diameter
tubo-ovarian abscess
-Complication of PID
-Tx: surgery or IR drainage
mature cystic teratomas
-MC form of ovarian teratoma
-Arise from ectodermal, mesodermal, and endodermal derivatives
-Usually occur in patients of reproductive age, but may be discovered at any age
-Usually benign, but 1-2% undergo malignant transformation
-Complications:
-Ovarian torsion
-Rupture
-Infection
-Autoimmune hemolytic anemia due to contents of teratoma (exceedingly rare)
-Malignant transformation
ovarian neoplasm incidence
-5-10% of women undergo surgery for ovarian mass
-20% of these are cancer
repeat US in pts with adnexal masses
-Repeat for: functional cysts, endometriomas, hydrosalpinges, simple cysts
-Timing: ~1 week after period in 2-3 cycles
A 53 yo G1P0010 LMP 2 years ago with history of Stage 3 breast CA diagnosed 5 years ago presents with incidental finding of complex L adnexal mass 4 months ago that was found to have increased in size by repeat ultrasound 2 weeks ago.
The mass is now 6.6x3.2x4.4 cm in size.
The patient admits to bloating and pelvic pain. She refuses physical examination or phlebotomy for tumor markers.
Refer to gyn onc for complex mass that increased in size with pelvic pain.
ovarian CA risk factors
-Age >55** most important
-FHx: ovarian/breast CA
-HNPCC, BRCA 1/2 status
ovarian CA risk reduction
-Bilateral oophorectomy: -May be recommended to pts with very strong family hx of ovarian and/or breast CA, or with +BRCA mutation status
-Does not yield 100% risk reduction, however
-Oral contraceptive use reduces risk by 40%; not as effective but helpful for pt with known + BRCA status
ovarian CA screening
-No current screening for average risk
-US +/- oophorectomy for high risk
PE of adnexal masses
-Limited utility for identifying masses
-Fixed, irregular, solid, bilateral mass or ascites = concern
interpreting US
-Assess: solid/cystic/complex, bilaterality, septations, excrescences, ascites, free fluid
- Solid
Definition: Mass is entirely composed of echogenic (white) material with no fluid content.
Implication: More concerning for malignancy, especially if irregular or vascular.
- Cystic
Definition: Mass is filled with anechoic (black) fluid and has thin, smooth walls.
Implication: Usually benign, like a functional cyst.
- Complex
Definition: Has both solid and cystic (fluid-filled) components.
Implication: Suspicious—may be:
Endometrioma
Hemorrhagic cyst
Malignancy
- Bilateral
Definition: Masses are seen on both ovaries.
Implication: Bilateral masses are more worrisome for metastatic disease (e.g. Krukenberg tumor) or epithelial ovarian cancer.
- Septations
Definition: Thin or thick walls dividing the cyst into compartments.
Thin septations → likely benign
Thick or irregular septations → concerning for malignancy
- Excrescences (Papillary Projections)
Definition: Nodular growths projecting into the cyst wall or cavity.
Implication: Highly suspicious for ovarian cancer
- Ascites
Definition: Free fluid in the peritoneal cavity (seen between organs)
Implication: Suggests peritoneal spread of cancer or rupture/hemorrhage
- Free Fluid
Definition: Fluid in the cul-de-sac (posterior to uterus)
Implication:
Small amounts: common in ovulation
Large amounts: may suggest rupture, bleeding, or malignancy
excrescences on US
Papillary projections suggest malignancy
- Nodular growths projecting into the cyst wall or cavity.
septations on US
-Septations increase suspicion for malignancy
- Thin or thick walls dividing the cyst into compartments.
color doppler US and malignant features
-Transvaginal US is best initial study to r/o a suspected adnexal mass
-Permits determination of blood flow to ovaries
-Malignant tissue has a higher oxygen demand due to lack of apoptosis and increased cell growth
-A “chaotic” vascular architecture is worrisome for malignancy
-pic- chaotic vascular architecture seen in US of ovarian sarcoma
malignant adnexal masses often have increased, disorganized blood flow on color Doppler.
other studies
-CT/MRI if US unclear
-Tumor markers used for monitoring and response to tx, not diagnostic
tumor markers
-CA-125: ↑ in 80% of ovarian CA, only 50% of Stage 1
-Can ↑ with pregnancy, leiomyomata uteri, and endometriosis as well as in liver disease
-Consider CA-125 testing to determine additional evidence that a complex mass is benign or malignant
-May be more beneficial in postmenopausal patients
