Ovarian Disorders Flashcards
What is PCOS?
Common endocrine disorder, characterised by excess androgen production and the presence of multiple immature follicles (“cysts”) within the ovaries
What are the hormone abnormalities seen in PCOS?
Excess luteinising hormone (LH) = prod by the AP gland in response to an increased GnRH pulse frequency.
This stimulates ovarian production of androgens
Insulin resistance = resulting in high levels of insulin secretion.
This suppresses hepatic prod of sex hormone binding globulin (SHBG), resulting in higher levels of free circulating androgens
Despite the high levels of LH, the increased circulating androgens suppress the LH surge (required for ovulation). Follicles devel within the ovary, but are arrested at an early stage (due to the disturbed ovarian function), they remain visible as “cysts” within the ovary
What are the signs and symptoms seen in PCOS?
- Hirsutism
- Oligomenorrhoea or amenorrhoea
- Infertility
- Obesity
- Chronic pelvic pain
- Depression (and other psychological symptoms)
- Acne
- Darkened skin (sec to insulin res)
How should PCOS be investigated?
Rotterdam criteria (need 2/3)
- Oligo- and/or anovulation
- Clinical and/or biochemical signs of hyperandrogenism
- Polycystic ovaries on imaging - string of pearls
Bloods = testosterone (raised), sex hormone-binding globulin (low), gonadotrophins (raised) and progesterone (low)
OGTT - women with PCOS at risk of DM
USS = peripheral ovarian follicles
List the risk factors for ovarian tumours
Nulliparity
Early menarche
Late menopause
Hormone replacement therapy containing oestrogen only
Smoking
Obesity
BRCA1 - 46% (at 70)
BRCA2 - 12%
Hereditary nonpolyposis colorectal cancer (Lynch II Syndrome)
What are the clinical features of ovarian tumours/cysts?
Asymptomatic
Chronic pain - sec to pressure on bladder/ bowel (constipation)
Acute pain - bleeding into the cyst, rupture or torsion
Vaginal bleeding
Bloating
Weight loss
Abdo/adnexal masses
How are ovarian cysts/tumours classified?
NON-NEOPLASTIC
- Functional:
- follicular cysts
- corpus luteal cysts
- Pathological:
- endometrioma
- polycystic ovaries
- theca lutein cyst
BENIGN NEOPLASTIC
- Epithelial tumours:
- serous cystadenoma
- mucinous cystadenoma
- brenner tumour
- Benign germ cell tumours:
- mature cystic teratoma
- Sex-cord stromal tumours
- Fibroma
How are cysts managed in premenopausal women?
No CA125
Under 40 - LDH, alphafetoprotein, hCG
Rescan in 6 weeks
<50mm = do not require follow up, almost always resolve within 3m
50-70mm = yearly USS
> 70mm = further imaging (MRI) or surgical intervention
How are cysts managed in postmenopausal women?
Low RMI (< 25): follow up 1 year with US and CA125 if <5cm.
Moderate RMI (25-250): bilateral oophorectomy and if malignancy found then staging is required (with completion surgery of hysterectomy, omentectomy +/- lymphadenectomy).
High RMI (>250): referral for staging laparotomy
What is RMI?
Risk of malignancy index
RMI = US x menopausal status x CA125
Outline the management of ovarian cysts
Surgery = staging laparotomy for those with a high RMI with attempt to debulk the tumour.
Adjuvant chemo = recommended for all patients apart from those with early, low grade disease and uses platinum based compounds.
Follow up = clinical exam and monitoring of CA125 level for 5 years with intervals between visits becoming further apart according to risk of recurrence.
How is PCOS managed?
Weight adjustment, COCP, cyproterone acetate, cyclical progestogen, metformin, ovulation induction in infertility, ovarian drilling
