Flashcards in Ovarian cysts (inc. PCOS) Deck (22)
What is PCOS? What are the 4 main symptoms of it?
Polycystic Ovarian Syndrome
Clinical hyperandrogenism (hirsuitism, acne)
Obesity and insulin resistance
What are the criteria to diagnose PCOS?
Need at least 2/3 of:
Hyperandrogenism (elevated serum total and free testosterone or DHEAS
Polycystic appearance of ovaries on U/S
Name 3 potential pathophysiological causes of PCOS
Androgen excess (adrenal or ovarian)
Abnormal LH secretion
Abnormal ovarian steroid synthesis
What is the definition of an ovarian cyst?
A fluid-filled, epithelial-lined sac in ovarian tissue
Name 5 causes/classifications of ovarian cysts and give an example of a cyst in each category
Physiological - exaggerated response to normal physiological process (follicular, endometrioid, corpus luteum cysts)
Infectious - abscess, or cystic collection of cellular debris (tubo-ovarian abscess)
Benign neoplastic - excessive growth of ovarian cells without dysplasia (fibroma, cystadenomas, mature teratoma/dermoid cyst)
Malignant neoplastic - excess growth with dysplasia (cystadenocarcinomas, endometrioid carcinoma, immature teratoma)
Metastatic (often from endometrial, colonic or gastric cancers)
Name 5 risk factors for developing an ovarian cyst
First trimester of pregnancy
Increased gonadotrophins (either endogenous - like beta-HCG release in pregnancy, or exogenous - like in infertility treatment)
Name 3 symptoms/signs of an ovarian cyst
Palpable mass on bimanual examination
Name 2 standard Ix for an ovarian cyst
Transvaginal U/S +/- Doppler studies
What is CA-125 primarily used for? Name 5 other cases where it may be elevated
Diagnosis of ovarian Ca. Can also be raised in women with gall bladder/pancreatic cancer, uterine fibroids, endometriosis, PID, adenomyosis, pregnancy and menstruation
A woman presents with acute-onset pelvic pain, signs of shock and vital sign abnormalities. Name 3 Ddx
Twisted ovarian cyst/torsion
Name 3 Ix if suspicious of an ovarian torsion, and expected results
Transvaginal U/S - look for ovarian enlargement
Doppler U/S - look for reduced venous flow
What are you most worried about if you find an incidental ovarian cyst in a post-menopausal women? Name 3 other symptoms associated with this condition. Name 3 further Ix to do.
Ovarian Ca. Other symptoms - abdo/pelvic pain, bloating, increased abdominal girth, early satiety, increased urinary frequency/urgency
Further Ix - Doppler U/S, CA125, laparotomy and oopherectomy for histopathology
Name 4 Ddx for an adnexal mass on U/S
Benign ovarian cyst (endometrioma, cystic teratoma)
Malignant ovarian cyst
What is the difference between CA-125 interpretation in a premenopausal and postmenopausal woman?
CA-125 needs to be much higher in a pre-menopausal woman before you start worrying about ovarian Ca (>200 U/mL vs > 35 U/mL) - lower prevalence of ovarian Ca + more false positives in younger women
What 3 factors does the Risk of Malignancy Index take into account for in determining ovarian Ca risk?
Name 3 features on U/S suggestive of a malignant ovarian cyst
Wall thickness/papillary structure
What are the two options for management of an ovarian cyst?
Leave it in (but monitor with follow-up every 3-4 months for U/S +/- CA125 if post-menopausal), or...
Cut it out!
Name 3 complications of an ovarian cyst
Ruptured cyst and bleeding/peritonitis
Name 2 risk factors for PCOS
Premature adrenarche (early onset pubic/axillary hair, sweat gland development)
Name 4 Ddx for PCOS, and an Ix to diagnose each condition
21-hydroxylase deficiency (blocks cortisol and aldosterone synthesis = shunts cortisol metabolism to make androgens) - look for elevated 17-hydroxyprogesterone
Hypo/hyperthyroidism (both lead to reduced ovulation/irregular menstruation) - TSH levels
Hyperprolactinaemia - prolactin levels
Cushing's syndrome (raises cortisol as well as androgen levels) - 24 hr urinary free cortisol
Androgen-secreting neoplasm (steroid-producing tumours of adrenals or ovary) - do imaging
Depression - ... whatever you do to diagnose depression
Name interventions for the three main symptoms of PCOS (subfertility, hyperandrogenism, irregular periods) - at least 2 for each symptom.
Weight loss, then metformin, then clomifene, then gondaotrophins, then IVF
OCP (works by inhibiting GnRH = inhibits ovarian androgen secretion, and increase SHBG = more binding of testosterone), antiandrogens (spironolactone, cyproterone, 5-alpha reductase inhibitors - finasteride), metformin, long-acting gonadotrophins
Weight loss, metformin (both induce ovulation), or OCP (progesterone exposure = sloughing of endometrium)