Ovarian Pathology

Question 1

What is the Rotterdam criteria in PCOS?

Answer 1

1. Oligoovulation or anovulation
2. Hyperandrogenism
3. Polycystic ovaries on USS (or ovarian volume >10cm3)

2 out of 3 of the criteria = diagnosis, particularly the first 2.

Question 2

What are the signs and symptoms of PCOS?

Answer 2

• Hyperandrogenism (Hirsuitism, male pattern balding, central obesity, acne)
• Subfertility/Infertility
• Oligo or amenorrhea
• Obesity (~70% of PCOS patients)

Question 3

What are the potential complications of PCOS?

Answer 3

• Increased risk of T2DM
• Inferility/Subfertility
• Complications related to obesity/metabolic syndrome
• Acanthosis nigricans
• Depression/anxiety
• Endometrial hyperplasia/endometrial cancer

Question 4

What is the expected LH:FSH ratio in a patient with PCOS?

Answer 4

Raised LH, thus a raised LH:FSH ratio

Question 5

What is the management of PCOS?

Answer 5

1. Weight loss (most important)
2. Low glycaemic index diet
3. Exercise
4. Antihypertension and statins if indicated by QRISK >10%
5. If not planning to get pregnant, consider COCP/Coil/etc to manage endometrial hyperplasia and hirsuitism
6. Anti-androgens for hyperandrogenism

Question 6

What are the main causes of ovarian torsion?

Answer 6

1. Usually a mass - either a cyst or tumour

2. In girls before menarche, it can occur due to longer infundibulopelvic ligaments

Question 7

How does ovarian torsion present?

Answer 7

Sudden onset severe unilateral pelvic pain

• Constant
• Progressively worsening
• Associated with nausea & vomiting

Examination:

• Localised tenderness
• Possibly a palpable mass

Question 8

How is ovarian torsion diagnosed?

Answer 8

1. Pelvic USS is initial investigation (TVUSS preferred):
   - May show ‘whirlpool sign’ of free fluid in the pelvis
   - May show ovarian oedema
   - Doppler may show restricted blood flow
2. Diagnostic laparoscopy is definitive

Question 9

What is the treatment of ovarian torsion?

Answer 9

Emergency laparoscopic surgery to either untwist the ovary or remove it

Question 10

What are the complications of ovarian torsion?

Answer 10

Ischaemia > Necrosis > Infection > Rupture > Peritonitis > Death

Question 11

What are ovarian cysts?

Answer 11

Fluid filled sacs in the ovaries

Functional ovarian cysts are related to the menstrual cycle and are extremely common in pre-menopausal women. Vast majority benign

Cysts in post-menopausal women are more concerning and warrant investigation.

Patients with multiple cysts or a ‘string of pearls’ finding on USS do not have PCOS unless they also fulfil another feature from the Rotterdam criteria

Question 12

What are the signs and symptoms of ovarian cysts?

Answer 12

Majority asymptomatic, but may cause:

• Pelvic pain
• Bloating
• Abdominal fullness
• Palpable pelvic mass

Question 13

What are the two types of functional ovarian cysts?

Answer 13

1. Follicular cysts:
   - Developing follicle that fails to rupture, leading to persistence of the cyst. Most common and usually resolve by next menstrual cycle.
2. Corpus luteum cysts:
   - When the corpus luteum fails to break down and fills with fluid. May cause pelvic pain, discomfort or delayed menstruation. Common in early pregnancy.

Question 14

What are the other types of ovarian cysts?

Answer 14

1. Serous cystadenoma:
   - Benign epithelial cell tumours
2. Mucinous cystadenoma:
   - Benign epithelial cell tumours, often very large
3. Endometrioma:
   - Lumps of endometrial tissue within the ovary; common in endometriosis
4. Dermoid cyst/Germ cell tumours:
   - Weird usually benign tumours that contain germ cell tissue, also known as teratomas. Pure horror
5. Sex cord stromal tumours:
   - Can be benign or malignant
   - Arise from connective tissue or sex cords (follicular embryonic structures)
   - Several types, including Sertoli-Leydig tumours and granulosa cell tumours

Question 15

What are the presenting features of ovarian cancer?

Answer 15

Often insidious - known as ‘silent killer’, symptoms are usually late sign and indicate metastatic disease

1. Persistent abdominal bloating (differentiate from digestive/IBS bloating by lack of variability)
2. Reduced appetite/early satiety
3. Unintentional weight loss
4. Night sweats
5. Urinary symptoms
6. Pain
7. Ascites
8. Lymphadenopathy

Question 16

What are the risk factors for ovarian cancer?

Answer 16

1. Post menopause
2. Advancing age
3. Increased number of ovulations (early menarche, late menopause, lack of hormonal contraception, nulliparity)
4. Obesity
5. HRT
6. BRCA genes/FHx
7. Smoking

Question 17

What are the investigations for ovarian cancer?

Answer 17

1. CA-125 tumour marker
   - not very specific
   - non-malignant causes of raised CA-125 include endometriosis, adenomyosis, fibroids, pregnancy, liver disease, pelvic infections
2. Investigate possible germ cell tumour in women under 40:
   - alpha fetoprotein
   - LDH
   - HCG
3. Imaging and investigations such as:
   - USS
   - Diagnostic laparoscopy

Question 18

Describe the Risk of Malignancy Index (RMI)

Answer 18

1. Menopausal status
2. USS findings
3. CA-125 levels

Question 19

What is Meigs Syndrome?

Answer 19

Triad of:

1. Ovarian fibroma
2. Pleural effusion
3. Ascites