1
Q
What is an ovarian cyst?
A
Fluid-filled sac in ovarian tissue
2
Q
What are the RFs for an ovarian cyst?
A
- Hx of ovarian cysts
- PCOS
- Endometriosis
- Pregnancy
3
Q
What are the types of ovarian cyst?
A
Physiological/Functional:
- Follicular
- Corpus luteal
- Haemorrhagic
- Theca lutein
Benign Germ Cell:
- Dermoid / Mature cystic teratoma
Benign Epithelial:
- Serous cystadenoma
- Mucinous cystadenoma
- Brenner’s Tumour
4
Q
Describe a follicular cyst
A
Dominant follicle fails to rupture
- Commonest type of ovarian cyst
- Lined by Granulosa cells
- May occasionally continue to produce oestrogen and lead to EH
- Commonly regress after several menstrual cycles
- Cyst = >3cm (>5cm is at risk of torsion)
- USS: thin walled, unilocular, anechoic
5
Q
Describe a luteal cyst
A
Dominant follicle ruptures but then closes again and fills with fluid, or can fill with blood (haemorrhagic)
- NORMAL in early pregnancy
- Lined by Luteal cells
- USS: diffusely thick wall, <3cm, lacey pattern
6
Q
Describe a haemorrhagic cyst
A
Bleeding into a functional cyst
7
Q
Describe a theca lutein cyst
A
Caused by overstimulation with HCG during pregnancy
- More common when higher HCG e.g. multiple pregnancy, GTD
- Often bilateral
- USS: bilaterally enlarged, multicystic ovaries, thin-walled and anechoic
- Resolve spontaneously
8
Q
Describe a dermoid cyst
A
- Most common benign tumour in those <30yo
- Lined by epithelial cells
- Benign, solid or cystic
- Often asymptomatic but most likely to tort
- Rokitansky protuberances = multiple or single white shiny masses that protrude out
- Mature: USS: unilocular, diffusely or partially echogenic, may contain teeth, no internal vascularity
- Immature: contains embryonic elements, malignant
9
Q
Describe a serous cystadenoma
A
The most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma)
- Usually unilocular
- Often bilateral
- USS: unilocular, anechoic, no flow on colour Doppler
10
Q
Describe a mucinous cystadenoma
A
- Typically very large
- If ruptures > pseudomyxoma peritonei (mucin in abdomen)
- USS: multiloculated, many thin separations, low echogenicity due to mucin
11
Q
Describe Brenner’s tumour
A
- Small
- Contain urothelial-like epithelium
- USS: hypoechoic, occasionally calcifications may be seen
12
Q
What are the S/S of an ovarian cyst?
A
- Lower abdominal pain
- Swelling with pressure symptoms (i.e. urinary symptoms)
- Deep dyspareunia
- Acute abdomen (torsion/haemorrhagic) – severe right or left iliac fossa pain (± vomiting in torsion)
13
Q
What are the investigations for an ovarian cyst?
A
- Exclude pregnancy
- Abdominal and vaginal examination
1st line = TVUSS
+Bloods:
Pre-menopausal:
- <40yo = LDH, aFP, b-hCG levels
Post-menopausal:
- CA-125
- RMI calculation
14
Q
What is the management of an acutely presenting ovarian cyst?
A
- ABC approach and resuscitate
- Ovarian cystectomy with oophorectomy if there is any necrosis
- Broad-spectrum antibiotics.
15
Q
What is the pre-menopausal management of an ovarian cyst?
A
Simple/unilocular cyst:
- <5cm = no follow-up required
- 5-7cm = repeat USS yearly
- > 7cm = MRI ± surgery
Recurrent or unresolved:
- Medical (COCP > preventing ovulation will prevent recurrent cysts)
Recurrent, sustained >5cm, suspicious/multiloculated:
- Surgical (laparoscopic cystectomy; usually curative)
16
Q
What are the indications for watchful waiting management of an ovarian cyst?
A
- Unilateral
- Unilocular (no solid parts)
- Pre-MP (3-10cm)
- Post-MP (2-6cm)
- Normal CA125
- No free fluid
17
Q
What is the post-menopausal management of an ovarian cyst?
A
If RMI >200 = CT-AP and MDT management with gynae-oncology
- Total abdominal hysterectomy (TAH), Bilateral Salpingo-Oophorectomy (BSO) ± Omentectomy
If RMI <200:
All of… asymptomatic, simple cyst, <5cm, unilocular, unilateral
= Repeat USS and Ca-125 in 4-6m:
- (1) Resolved = Discharge
- (2) Unchanged = Repeat USS and Ca-125 in 4-6m
- (3) Changed = Consider intervention (laparoscopic cystectomy)
Any of… symptomatic, non-simple features, >5cm, multilocular, bilateral
= BSO
18
Q
What are the complications of an ovarian cyst?
A
Ovarian cyst rupture
- Most common with functional cysts
- Conservative (pain relief) + watchful waiting
- Laparoscopy ± cautery (if evidence of active bleeding)
Also:
- Ovarian torsion (if >5cm; most common in dermoid)
- Subfertility
- Malignant change
- Oophorectomy
19
Q
What is an ovarian tumour?
A
Tumours arising from the ovary. Can be classified into benign or malignant, or by type.
20
Q
What are protective factors against ovarian tumours?
A
- Pregnancy
- COCP
21
Q
What are RFs for ovarian tumours?
A
- More ovulations; i.e. nulliparity, early menarche, late menopause
- Increasing age
- FHx (BRCA1/2, MLH1, MSH2)
- Endometriosis
- HRT
- Obesity, smoking
- Talcum powder
22
Q
What is associated with ovarian tumours?
A
- Lynch syndrome (Autosomal Dominant HNPCC; MLH-1, MSH-2)
- Breast cancer (BRCA1/2)
- Many genetic associations exist (p53 (serous), BRAF, K-ras)
23
Q
What are the main types of ovarian tumour?
A
- Epithelial (70%) - most common
- Germ-Cell (15%)
- Sex-Cord Stromal (5%)
- Benign tumours
24
Q
Describe epithelial ovarian tumours
A
- Originates from the epithelium covering the ovary
- Post-menopausal (56yo)
- Present LATE with a BAD prognosis
- Endometriosis association with clear cell (>20%) > endometrioid (10-20%) ovarian cancer
- Endometroid ovarian carcinoma often found alongside endometroid endometrial carcinoma
Type 1:
- Low-grade serous (solid or cystic, most common)
- Endometrioid (solid or cystic)
- Mucinous (solid or cystic)
- Clear cell tumour
Types 2:
- High-grade serous (solid or cystic)
25
Describe germ cell ovarian tumours
- Undifferentiated primordial germ cells of the gonad.
- Bimodal - Young premenopausal or postmenopausal women (15-20yo > 65-70yo)
- Hilus cell tumours = Leydig cell tumours; secrete androgens
**Types:**
- Teratoma (solid or cystic, majority) - most common benign growth <30yrs
- Dysgerminoma
- Endodermal sinus tumour
- Choricocarcinoma
26
Describe sex-cord stromal ovarian tumours
- Originates from the stroma of the gonad
- All Ages (post-menopausal)
**Types:**
- Fibroma - no endocrine function
- Thecoma - oestrogen
- Granulosa cell tumour - oestrogen
- Sertoli-Leydig cell tumour - androgens, variable
27
What are the S/S of ovarian tumours?
*Vague symptoms > late presentations…*
**Late presentation – 75% present in Stage 3**
- Lower abdominal pain
- Deep dyspareunia
- Pressure symptoms
- Abdominal swelling
- (note: may be asymptomatic).
**Acute accident:**
- Severe right or left iliac fossa pain, accompanied by vomiting in torsion.
**Vague/ absent symptoms:**
- Abdominal discomfort
- Abdominal distension/mass
- Fatigue, weight loss,
- Pressure symptoms (urinary frequency/dyspepsia).
28
What are the differences between ovarian and endometrial cancer?
Ovarian = adnexal mass and no PV bleeding
Endometrial = uterine mass and PMB
29
What are the investigations for ovarian tumours?
**1st = CA125**
- If ≥35 = 2ww referral to O&G and USS of abdomen and pelvis
- *CA125 also raised in pregnancy, endometriosis and alcoholic liver disease*
**2nd = USS abdo and pelvis**
*Characterise:*
- Size, Consistency, Presence of solid elements, Bilateral or not, Presence of ascites, Extraovarian disease (peritoneal thickening and omental deposits)
**3rd = RMI**
- Score >250 is considered high-risk (<25 is low risk) = Refer to specialist MDT
**4th = CT scan abdo and pelvis**
- Establish extent of disease / Staging
**5th = Histopathology**
- Definitive diagnosis
30
What is the management of an ovarian tumour?
**Chemotherapy:**
- Offer women with high risk stage I disease (grade 3 or stage Ic) adjuvant chemotherapy consisting of 6 cycles of carboplatin
**Surgery:**
- Midline Laparotomy: TAH + BSO + omentectomy
31
What are the complications of ovarian tumours?
- Prognosis – most important prognostic factor is no residual disease following laparotomy
- Depends on stage, volume of disease following surgery and histological grade
- 5-year survival = 46% (stage 1 = 90%; stage 3 = 30%)
32
What is ovarian torsion?
The partial or complete torsion of the ovary on it's supporting ligaments that may in turn compromise the blood supply.
- If the fallopian tube is also involved then it is referred to as adnexal torsion.
33
What are the RFs for ovarian torsion?
- Ovarian cysts or tumours
- Long ovarian ligaments
- Pregnancy
- Tubal ligation
- ovarian hyperstimulation syndrome
- being of a reproductive age
34
What are the S/S of ovarian torsion?
- Usually the sudden onset of deep-seated colicky abdominal pain.
- Severe right or left iliac fossa pain
- Unlikely to have shoulder-tip pain (differentiate from ectopic)
- Associated with vomiting and distress
- fever may be seen in a minority (possibly secondary to adnexal necrosis)
- Vaginal examination may reveal adnexial tenderness
35
What are the investigations for ovarian torsion?
- Pregnancy test
- FBC (may show high WCC)
- Speculum (if PID is a differential)
- Bimanual examination (adnexal mass) – this is ok in ovarian torsion
- Urinalysis (rule out ureteric colic)
**Urgent TVUSS with Dopplers**
- 25% of torsion occurs in children (do transabdominal rather than TVUSS)
- Torsion of a normal ovary is VERY unlikely
- Ovarian necrosis may cause lactic acidosis
- May show free fluid or a whirlpool sign.
**Laparoscopy usually diagnostic and therapeutic**
36
What is the management of ovarian torsion?
- 1st line: laparoscopic detorsion ± cystectomy (if required)
- 2nd line: salpingo-oophorectomy
If surgery is not prompt enough, removal of a necrotic ovary may be necessary
37
Describe the different types of incontinence
**Stress:**
- Increased pressure on bladder > incontinence
- [SMALL LOSSES] - e.g. leaking small amounts when coughing or laughing
**Urge:**
- Strong urge to urinate and often don’t get to toilet in time > incontinence
- [LARGE LOSSES] - due to detrusor overactivity, the urge to urinate is quickly followed by uncontrollable leakage ranging from a few drops to complete bladder emptying
**Mixed:**
- ≥2 types (often stress and urge incontinence together)
**Overflow:**
- Difficulty emptying bladder > filling > incontinence
**Functional:**
- Cannot get to the toilet in time (issues in mobility) > incontinence
38
What are the RFs for overactive bladder syndrome?
- Advancing age
- Previous pregnancy and childbirth
- High BMI / obesity
- Hysterectomy
- FHx
39
What are the investigations for overactive bladder syndrome?
- **Speculum:** Exclude pelvic organ prolapse, check ability to initiate voluntary contraction of pelvic floor muscles ('Kegel' exercises), ask patient to cough (Valsalva) to check for fluid leakage
- **Urine dipstick, urine MC&S** – rule out DM or UTI
- **Bladder diaries** (minimum 3 days) > if inconclusive move to 2nd line…
- **2nd: Urodynamic Testing** (if mixed incontinence) – 3 pressures measured from inside rectum and urethra
40
What is the management of stress incontinence?
CHECK NEED FOR REFERRAL TO SPECIALIST
(i.e. trigone tumour > needs to be checked)
**1st line = Conservative:**
- WL (if BMI >30)
- Pelvic floor exercises (8 contractions, TDS, 3 months)
- Can refer to physiotherapist if difficulty with pelvic floor exercises
**2nd line = Surgical treatment**
- **Colposuspension:** Stitching neck of bladder higher
- **Autologous rectus fascial sling:** A sling placed around the neck of the bladder
- **Bulking agents:** bulking agents injected into urethral sphincter to strengthen it
**SNRI duloxetine:**
- if does not want surgical treatment
41
What is the management of urge incontinence?
CHECK NEED FOR REFERRAL TO SPECIALIST
(i.e. trigone tumour > needs to be checked)
**1st line = Conservative:**
- Bladder training (lasts for a minimum of 6 weeks, idea is to gradually increase the intervals between voiding (up to 25 minutes)
- Avoid fizzy drinks (carbonic acid can stimulate detrusor muscles)
- Control any diabetes well (avoid diabetic nephropathy)
**2nd line = Bladder stabilising drugs:**
- 1st = Antimuscarinics (oxybutynin, tolterodine)
- Oxybutynin = increased risk of falls – do not give if frail and elderly
- Mirabegron (beta-3-agonist) used if concerns about using anticholinergics in older, frail women
**3rd line (surgical)**
- Botox injection - risk of urinary incontinence intermittently requiring self catheterisation
- Neuromodulation - sacral nerve stimulation, percutaneous tibial nerve modulation
42
What is the management of overflow incontinence?
- Refer to specialist urogynaecologist
- 1st line = timed voiding
43
Post-partum dribbling incontinence?
Dribbling incontinence after having a child with a prolonged labour, suspect a vesicovaginal fistula > urinary dye studies
44
What is PCOS?
**A common condition that affects how your ovaries work (1 in 10)**
*The 3 main features of PCOS are:*
- **Irregular periods** – which means your ovaries do not regularly release eggs (ovulation) and you may find it hard to get pregnant
- **Excess androgen** – high levels of "male" hormones in your body, which may cause physical signs such as excess facial or body hair
- **Polycystic ovaries** – your ovaries become enlarged and contain many fluid-filled sacs (follicles) that surround the eggs
45
What are the RFs for PCOS?
FHx, obesity
46
What are the S/S of PCOS?
- Hirsutism (upper lips, lower abdomen)
- Sub-fertility
- menstrual disturbances: oligomenorrhoea and amenorrhoea
- Weight gain, acne
- Insulin resistance > acanthosis nigricans
47
What are the investigations for PCOS?
- **Examination:** Hirsutism, acne, obese
- **Obs** + **BMI**
- **Bloods:** high cholesterol, prolactin, testosterone, LH (raised LH: FSH index i.e. LH > FSH; 2: 1 or 3: 1), SHBG normal to low
- **OGTT**
- **TVUSS** = multiple fluid filled cysts (“Pearl Necklace” sign)
**DM monitoring:**
*OGTT at diagnosis for…*
- BMI ≥25
- Non-Caucasian ethnicity
- Any BMI and >40yo, FHx DM, GDM hx
*Annual OGTT for…*
- IFG (fasting 6.1-6.9mmol/L)
- IGT (OGTT 7.8-11.1mmol/L)
**CVD monitoring (assess risk with QRISK2):**
- Lipid profile
- Blood pressure
- Diet, exercise, smoking and weight loss
48
What is the Rotterdam Criteria?
For PCOS (≥2 of the following):
- Oligo/anovulation (>2 years)
- Clinical or biochemical features of hyperandrogenism
- Polycystic ovaries on USS (>12 in ≥1 ovary measuring 2-9mm OR increased ovarian volume ≥10cm3)
49
What is the management of PCOS?
**General:**
- Weight loss - diet and exercise
**Irregular periods:**
*(Oligomenorrhoea (≥3m) = refer for TVUSS to assess endometrial thickness)*
- COCP to induce regular monthly bleed
- LNG-IUS
**Hirsutism and Acne:**
- 1st line: COCP or co-cyprindiol
- If no response = Topical eflornithine cream
**Infertility:** Should be managed by a specialist
- 1st line: weight loss if appropriate
- 2nd line (up to 6 months): clomiphene +/- metformin (after 3 failed clomiphene cycles)
-Induces ovulation
-Increased risk of multiple pregnancy
- 3rd line: gonadotrophins, IVF (risk: OHSS)
- Surgery: laparoscopic ovarian drilling / LOD (destroy ovarian stroma and prompt cycles)
50
What are the complications of PCOS?
- Metabolic syndrome (DM and heart disease)
- Sleep apnoea
- Cardiovascular disease
- Endometrial cancer (if >7mm, may be pathological)
- Recommend withdrawal bleed every 3-4 months
- Subfertility
51
What is premature ovarian insufficiency (POI)?
The onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years.
(secondary amenorrhoea before the age of 40 years)
52
What is the difference between the menopause and POI?
POI = ovulate sporadically
Menopause = stopped entirely
53
What are the causes of POI?
- **Idiopathic** (most common cause, may be FHx)
- Radiotherapy, chemotherapy
- Autoimmune disorders
- Bilateral oophorectomy (having a hysterectomy with preservation of the ovaries has also been shown to advance the age of menopause)
- Infection: e.g. mumps
- Resistant ovary syndrome: due to FSH receptor abnormalities
- Unknown (Addison’s– steroid cell autoantibodies cross-react with granulosa cells and theca interna)
54
What are the S/S of POI?
- Menopause signs & symptoms
- climacteric symptoms: hot flushes, night sweats
- infertility
- secondary amenorrhoea
55
What are the investigations for POI?
**Diagnosis = <40yo, 2 x FSH results >30** (these should be 4-6 weeks apart) **+ menopause symptoms**
- Oestrogen [LOW], FSH/LH [HIGH]
- Antral follicle count, AMH levels [test ovarian reserve] – helpful, but don’t base diagnosis off of this
56
What is the management of POI?
**Lifestyle, HRT and non-HRT management**
HRT or a COCP should be offered to women until the age of the average menopause (51 years)
**Fertility management:**
- Donor oocyte IVF
- Surrogacy and adoption are other options
- Support groups
57
What are the complications of POI?
- Osteoporosis: regular DEXA scans, all of them should get HRT
- Other: hypothyroid, sexual dysfunction, insomnia (vasomotor symptoms), stroke, heart disease
- N.B. menopause (over 45 years) is a retrospective clinical diagnosis, whereas POI is a biochemical diagnosis
O&G
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