The ovary and its disorders

Question 1

Anatomy and function of the ovaries

Answer 1

ovarian carcinoma most commonly derives from germinal epithelium

oestrogen secreted by granulose cells in growing follicles and theca cells

FSH enlarge some follicles every month

• reaches 20mm and ruptures IRT mid-cycle surge of LH → oocyte release
• follicle → corpus luteum → produces P+O to support endometrium whilst awaiting fertilisation and implantation → hCG produced by trophoblasts maintain CL function and hormone production until 7-9 wks gestation when the fetoplacental unit takes over
• if no fertilisation → CL involutes, hormone levels decline → MENSTRUATION

Question 2

Ovarian cyst ‘accidents’

Answer 2

1. Rupture of ovarian cyst into peritoneal cavity (e.g. endometrioma or dermoid cyst) → intense pain
2. Haemorrhage into a cyst → pain, can cause hypovolaemic shock
3. Torsion of pedicle (bulky due to the cyst) → infarction of ovary and tube → severe pain → urgent surgery and detorsion required if ovary to be saves

most ovarian masses silent and detected when very large/abdominal distension/USS

acute presentation is associated with ‘accidents’

Question 3

3 disorders of ovarian function

Answer 3

PCOS = oligomenorrhoea, hirsutism, sub-fertility. Cysts small multiple poorly developed follicles

Premature menopause = last period reached before 40 y/o

Problems of gonadal development = gonadal dysgenesis e.g. Turner’s Syndrome

Question 4

Classification of ovarian tumours:

primary neoplasms = benign/malignant

→ epithelial tumours, germ cell tumours, sex cord tumours

Answer 4

most common in postmenopausal women, ovarian epithelium or Fallopian tube

usually ‘borderline’ malignancy (histological features, no invasion), can become malignant → surgery advised

younger women with borderline → observation following removal of cyst or affected ovary to retain fertility, recurrence 20 years later

1. serous cystadenoma or adenocarcinoma
   * most common malignant neoplasm, high grade (70%) or low grade (<5%)
2. endometrioid carcinoma
   * 10% of ovarian malignancies, associated with endometrial carcinoma
3. clear cell carcinoma
   * 10% of ovarian malignancies, poor prognosis
4. mucinous cystadenoma or adenocarcinoma
   * can become very large, 3% ovarian malignancies
5. Brenner tumours
   * small and benign

Question 5

Classification of ovarian tumours:

primary neoplasms = benign/malignant

→ epithelial tumours, germ cell tumours, sex cord tumours

Answer 5

From undifferentiated primordial germ cells of gonad, 3% ovarian malignancies

1. Teratoma/dermoid cyst

• common benign tumour, young premenopausal women
• commonly bilateral, seldom large, often asymptomatic
• rupture painful
• malignant form = solid teratoma, very rare

2. Yolk sac tumours
   * highly malignant, present in children and young women

3. Dysgerminoma

• female equivalent of seminoma
• rare
• most common ovarian malignancy in younger women
• sensitive to radiotherapy

Question 6

Classification of ovarian tumours:

secondary malignancies → tumour-like conditions (cysts)

Answer 6

endometriotic cysts = chocolate cysts, in the ovary they are called endometriomas, rupture very painful but uncommon

functional cysts = follicular cysts/lutein cysts are persistently enlarged follicles and CL

• only found in premenopausal women
• combined pill protects against these by inhibiting ovulation
• lutein cysts cause more symptoms
• if asymptomatic → tx not required, cyst observed using serial USS
• if cyst >5cm more than 2 months → CA 125 level measured and laparascopy to remove/drain cyst

Question 7

Classification of ovarian tumours:

primary neoplasms = benign/malignant

→ epithelial tumours, germ cell tumours, sex cord tumours

Answer 7

from stroma of gonad and account for <2% of ovarian malignancies

granulosa cell tumours = malignant, slow-growing, rare, post-menopausal women

• secrete high levels of oestrogen and inhibin → stimulation of endometrium → bleeding, endometrial hyperplasia, enomdetrial malignancy, and precocious puberty (rarely, young girls)
• serum inhibin levels used as tumour markers to monitor for recurrence

thecomas = rare, benign, secretes oestrogen a/o androgens

fibromas = rare, benign

• → Meig’s syndrome = ascites and right pleural effusion found in conjucntion with small ovarian mass, effusion is benign nd cured by removal of mass

Question 8

Ovarian cancer: epidemiology, what reduces risk?

Answer 8

silent nature of malignancy → late presentation so widely metastatic within abdomen

10-year survival rate = 40-50%

avg. 63 y/o

OCP reduces risk

Question 9

Histological types of primary ovarian malignancy: SECMO

Answer 9

Question 10

Ovarian cancer: pathology (most common type)

Answer 10

95% epithelial carcinomas BUT germ cell tumours are most common in the rare event of a women under 30 y/o being affected

grade = borderline, low, high

Question 11

Ovarian cancer: aetiology and RFs

Answer 11

benign cysts can undergo malignant change

• RFs = nulliparity, early menarche, late menopause
• Protective = pregnancy, lactation, the pill use

Familial

• ovarian carcinoma (BRCA1/BRCA1/HNPCC)
• BRCA1 50% risk
• BRCA2 associated with breast cancer
• HNPCC (Lynch Syndrome) associated with bowel and endometrial cancer

Question 12

Screening for ovarian cancer

Answer 12

no UK national screening programme

screening for early malignant rather than pre-malignant disease

• genetic counselling with FHx of BRCA1/BRCA2
• those with mutations are offered prophylactic salpingo-oophorectomy

Question 13

Ovarian cancer: clinical features

Answer 13

History

• vague/absent early, 70% stage 3-4 present
• abdominal distension or mass palpated by patient
• early satiety and/or loss of appetite, pelvic/abdominal pain
• urinary urgency and/or frequency
• vaginal bleeding
• ASK ABOUT breast and GI sx (metastasis)

Examination

• cachexia
• abdominal/pelvic mass (very large less likely to be malignant)
• ascites
• PALPATE BREASTS (metastasis)

Question 14

Is the ovarian mass malignant?

Answer 14

Question 15

Spread and staging for ovarian cancer

Answer 15

Question 16

Ovarian cancer: Investigations initial detection (primary care)

Answer 16

CA 125 in women >50 y/o with many abdominal sx’s

• raised (>35 IU/mL) → USS of abdopelvis
• if ascites/abdopelvic mass found → refer to secondary care

REALITY = CA-125 + USS + urgent referral to GYN

Question 17

Ovarian cancer: Establishing the diagnosis (secondary care)

Answer 17

CA-125 + USS if not already arranged

CT abdopelvis (+thorax if clinically indicated) to establish extent of disease

• further staging usually performed using surgery

<40 y/o = AFP + hCG

RMI (risk of malignancy index) = U x M X CA125

• U is USS score, 1 point for each = multilocular cysts, solid areas, metastases, ascites, bilateral lesions
• U = 1 for score of 1 point
• U = 3 for score of 2-5 points
• M is menopausal status
• M = 1 premenopausal
• M = 3 postmenopausal
• RMI >250 refer to specialist MDT

Question 18

Management of ovarian cancer (mx guide)

Answer 18

Question 19

Palliative care: NSAID/pain ladder

Answer 19

Co-analgesics = antidepressants, steroids, cytotoxic

opioid analgesia can be patient controlled + anti-emetics

alternative therapies = acupuncture, behavioural techniques

Question 20

Palliative care: N+V

Answer 20

causes = opiates, metabolic causes (e.g. uraemia), vagal stimulation (e.g. bowel distension), psychological cfactors

tx = antiemetics → anticholinergics, anti-histamines, dopamine antagonists or 5HT-3 antagonists (e.g. ondansetron)

Question 21

Palliative care: heavy vagina bleeding

Answer 21

tx = high dose progestogens, radiotherapy

Question 22

Palliative care: ascites and bowel obstruction

Answer 22

drain ascites by repeated paracentesis

obstruction managed at home

• partial = metoclopramide (pro-motility and anti-emetic), stool softeners, enemies for constipation, trial of dexamethasone to reduce tissue oedema
• complete = cyclizine + ondansetron for N+V, hyoscine for spasm
• eat and rink small amounts
• surgical = stents inserted in sigmoid colon or rectum

Question 23

Palliative care: terminal distress

Answer 23

anxiolytics and analgesics

Question 24

Classifications of ovarian tumours at a glance

Answer 24

Question 24

Classifications of ovarian tumours at a glance

Answer 24

Question 25

Carcinoma of the ovary at a glance

Answer 25

Question 26

Ovarian cysts: types

Answer 26

Complex (i.e. multi-loculated) ovarian cysts should be biopsied to exclude malignancy.

Question 27

ovarian cyst rupture

Answer 27

An ovarian cyst is most likely to rupture during physical activity (e.g. sexual intercourse, exercise). **Clinical features** * Symptoms range from asymptomatic, acute unilateral pain, to intra-peritoneal haemorrhage with haemodynamic compromise. **Differentials** * Differentials include ovarian torsion and ectopic pregnancy are other causes of acute onset of unilateral pain. Gastrointestinal causes such as appendicitis should also be considered. **Investigations** * TVUS for ovarian pathology * Investigations involve a pregnancy test to exclude ectopic. Diagnostic laparoscopy may be needed in an unstable patient. **Management** * Management is mostly conservative, but in extreme cases surgery is needed.

Question 28

Premature ovarian failure

Answer 28

Premature ovarian failure is defined as the onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years. It occurs in around 1 in 100 women. TO MAKE DIAGNOSIS = hormones need to be elevated when tested TWICE, FOUR weeks apart Causes of premature menopause include: * idiopathic * the most common cause * there may be a family history * bilateral oophorectomy * having a hysterectomy with preservation of the ovaries has also been shown to advance the age of menopause * radiotherapy * chemotherapy * infection: e.g. mumps * autoimmune disorders * resistant ovary syndrome: due to FSH receptor abnormalities Features are similar to those of the normal climacteric but the actual presenting problem may differ * climacteric symptoms: hot flushes, night sweats * infertility * secondary amenorrhoea * raised FSH, LH levels * e.g. FSH \> 40 iu/l * low oestradiol * e.g. \< 100 pmol/l Mx: The patient should be treated with hormone replacement therapy (HRT) until at least the age of normal menopause (51), unless the risks of HRT treatment outweigh the benefits.