Ovarian disorders Flashcards
(20 cards)
What is PCOS? Ax?
- PCOS is a common endocrine disorder characterised by excess androgen production and presence of multiple immature follicles (cysts) within the ovaries.
- Most common clinical features include infertility, amenorrhoea, acne and/or hirsutism.
- Ax poorly understood (multifactorial)
Ax of PCOS?
2 most common hormonal abnormalities in PCOS:
1) Excess luteinising hormone (LH) - produced by anterior pituitary stimulated by GnRH, stimulates ovarian production of androgens.
2) Insulin resistance - high levels of insulin secretion, suppressing hepatic production of sex hormone binding globulin (SHBG) - higher levels of free circulating androgens.
PPx of PCOS?
Despite the high levels of LH, increase in free circulating androgens suppress the LH surge (required for ovulation to occur). Follicles develop within the ovary but are arrested at an early stage (due to disturbed ovarian function) - remain visible as cysts within the ovary.
RF:
1) Diabetes
2) Irregular menstruation
3) FH of PCOS
Clinical features of PCOS?
1) Oligomenorrhoea/amenorrhoea
2) Obesity
3) Hirsutism
4) Chronic Pelvic pain
5) Infertility
6) Depression
7) Acne
8) Male pattern baldness
9) Acanthosis Nigricans (darkened skin secondary to insulin resistance)
Ddx of PCOS?
1) Hypothyroidism (obesity, hair loss and insulin resistance)
2) Hyperprolactinaemia (oligo/amenorrhoea, acne, hirsutism)
3) Cushing’s disease (obesity acne, hypertension, insulin resistance and depression)
Investigations/Diagnosis of PCOS?
- ROTTERDAM CRITERIA - 2 out of 3:
1) Oligo/amenorrhoea (an ovulation)
2) Biochemical or clinical signs of hyperandrogegism
3) Polycystic ovaries on imaging
-Blood tests: testosterone (raised), SHBG (low), FSH (normal), LH (raised), progesterone (low)
(FSH + LH best measured in first 3 days of menstrual bleed, ratio important - LH:FSH > 3:1 can cause disruption to ovulation.
- Blood tests for exclusion - TFT (hypothyroid), serum prolactin (hyper).
- Oral glucose tests in women BMI >30 - increased risk of diabetes.
IMAGING:
Pelvic Ultrasound - numerous peripheral ovarian follicles (cysts) and enlarged >10cm^3.
Management of PCOS?
First treat any underlying conditions such as diabetes or hypertension.
- Oligomenorrhoea/Amenorrhoea: Effect of oestrogen unopposed due to low levels of progesterone - endometrial hyperplasia with risk of malignancy. PROTECT ENDOMETRIUM by inducing 3 bleeds a year - COCP (low dose) or dydrogesterone (progesterone analogue) used if COCP if contraindicated.
Obesity: Weight management crucial (BMI <30) 0 exercise, and healthy diet, increasing insulin sensitivity. Severe cases give Orlistat (pancreatic lipase inhibitor).
Infertility: Clomifene and Metformin helps induce ovulation - first line for women wanting to conceive. Increased risk of multiple pregnancies, ovarian hyperstimulation syndrome and ovarian cancer.
- Women with a normal BMI could also benefit from laparoscopic ovarian drilling.
Hirsutism: Antiandrogen medication - finasteride/spironolactone/cyproterone. AVOID during PREGNANCY.
- Elfornithene - topical cream reduces rate of hair growth.
What is an ovarian cyst?
- An ovarian cyst is a fluid filled sac within the ovary - common in premenopausal patients where benign cysts occur throughout menstrual cycle.
- Women presenting with small cysts should not raise concern unless symptomatic - resolution confirmed few weeks down the line.
- Concern with ovarian masses - presence of malignancy - risk of malignancy index (RMI) is a tool used in practice to determine likelihood of this allows triage and referral to a cancer centre for treatment.
Risk factors for ovarian cysts/tumours?
- Ovarian tumours derive from surface epithelial irritation during ovulation, more ovulations that take place the increased risk of malignancy.
RF: Nulliparity, early menarche, late menopause, hormone replacement therapy containing oestrogen only, smoking and obesity.
Protective factors: Multiparity, COCP, breastfeeding
Genetic component to ovarian cancer - herited genetic mutations?
1) BRCA1 and 2 genes - increase risk of breast and ovarian cancers, increased risk with age (at 70yrs 46% in BRCA1 and 12% in BRCA2) - prophylactic bilateral salpingo-oopherectomy - does not completely eradicate risk.
2) Hereditary nonpolyposis colorectal cancer (Lynch II syndrome) - rare syndrome with an associated risk of developing colorectal and endometrial cancer - and lifetime risk of developing ovarian cancer.
Risk of malignancy index (RMI):
- M x U x CA125 = RMI
M - premenopausal (1 point), postmenopausal (3 points)
U - 1 of following feature (1 point), 2 or more features (3 points): Ultrasound score list - multiloculated cyst, solid areas, metastases, bilateral lesions, ascites
CA125 - Cancer antigen 125 given measured in blood test, given as a value in units/ml.
RMI >250 needs referral to specialist gynaecologist.
Clinical features of Ovarian Cysts/tumours?
1) Incidental/asymptomatic
2) Chronic pain - due to pressure on bladder/bowel
3) Constipation/frequency/bloating - due to pressure on bladder/bowel
4) Dyspareunia/cyclical pain due to endometriosis with chocolate cysts.
5) Acute pain - rupture/bleeding or torsion of cyst
7) Bleeding per vagina
8) Weight loss
A patient may present with shock after rupture or torsion, following this, look for abdominal masses arising from the pelvis and ascites. Examine pelvis for discharge/bleeding, adnexal masses, and cervical excitation, may need resuscitation.
What is a simple cyst and a complex cyst?
Simple Cyst - one that contains only fluid
Complex ovarian cyst - can be irregular and contain solid material, blood or have separations/vascularity
Non-neoplastic cysts:
- NO MALIGNANT POTENTIAL
Functional:
1) Follicular cysts - less than 3cm and represent developing follicles in follicular phase
2) Corpus luteal cysts - less than 5cm and occur in luteal phase after formation of corpus luteam.
Pathological:
1) Endometrioma - chocolate cysts in those with endometriosis. Bleeding into the cyst causes this appearance.
2) Polycystic ovaries - ultrasound diagnosis - more than 12 antral follicles + ovarian volume greater than 10ml - ‘ring of pearls’ sign seen on scanning, PCO one feature of PCOS, does not equate to.
3) Theca Lutein cyst - due to markedly high hCG e.g. molar pregnancy - regress upon resolution of the hCG.
Benign neoplastic cysts:
Epithelial:
1) Serous cyst adenoma - most common malignant ovarian tumour (unilocular usually), 30% bilateral.
2) Mucinous cyst adenoma - multiloculated and are usually unilateral
3) Brenner tumour - unilateral with solid grey/yellow appearance
Benign germ cell tumours:
1) Mature cystic teratoma (DERMOID cysts) - usually in young women, and common in pregnancy. Can contain teeth, hair, skin and bone.
Sex-cord stromal tumours:
1) Fibroma - (important) In up to 40% with Meig’s syndrome - association between these tumours and ascites/pleural effusion.
Management of Ovarian Cysts (in premenopausal pts)?
Premenopausal:
1) CA125 does not need to be undertaken if simple ovarian cyst diagnosed through ultrasound. CA125 can be raised by anything that irritates the peritoneum (numerous benign triggers).
2) Lactate dehydrogenase, alphafetoprotein, hCG should be measured <40 - germ cell tumours?
3) Rescan cyst in 6 weeks - if persistent monitor with ultrasound and CA125, 3-6 monthly and calculate RMI.
4) If persistent or over 5cm consider laparoscopic cystectomy, or oophorectomy.
Management of Ovarian Cysts (in postmenopausal pts)?
1) LOW RMI (<25) - follow up 1 year with ultrasound and CA125 if less than 5cm.
2) Moderate RMI (25-250) - Bilateral oophorectomy and if malignancy found than staging is required (with completion surgery of hysterectomy, omentectomy, and lymphadenectomy).
3) High RMI (>250) - referral for staging laparotomy.
Types of ovarian cancer?
1) Serous cystadenocarcinoma - Psammoma bodies
2) Mucinous cystadenocarcinoa - mucin bodies
Dx of Ovarian cancer?
- All pts with suspected ovarian cancer: FBC, U+E, LFT and albumin.
- NICE recommends abdominal and pelvic ultrasounds for pelvic masses - RMI can be calculated.
- Confirmed cancer - CXR, abdominal/pelvic CT should be undertaken for staging and pre-op process.
Management of ovarian cancer?
1) Surgery - staging laparotomy for those with high RMI and attempt to debulk tumour.
2) Adjuvant chemotherapy - recommended for all patients apart from those with early low grade disease and uses platinum based compounds.
3) Follow up - involved clinical examination and monitoring of CA125 for 5 years with intervals between visits becoming further apart to risk of recurrence.
