Week 5 pt 1 Flashcards by Morgan Evans

What is included in the adnexa?

1) Ovaries
2) Fallopian tubes
3) Upper portion of the broad ligament and mesosalpinx
4) Remnants of the embryonic Mullerian duct

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Where may adnexal masses originate?

May originate in the reproductive system or nearby

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Give some DDxs for adnexal masses

-UTI
-Pyelonephritis
-Renal and Ureteral Calculi
-Ptotic Kidney
-Appendicitis
-Inflammatory Bowel Disease
-Diverticular Disease
-Rectosigmoid Carcinoma

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List the most common Sxs of adnexal neoplasms

1) Abdominal bloating/distention (most common early)
2) Abdominal or Pelvic Pain
3) Decreased Energy
4) Early satiety
5) Urinary urgency

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1) What should PE include for eval. of ovarian disease?
2) How common/ uncommon are Malignant Ovarian Masses?

1) Bimanual Exam: Ovaries should not be palpable in most cases
2) 30% of palpable masses in postmenopausal women
10% of palpable masses in reproductive-aged women

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Describe imaging for adnexal masses

1) Primary imaging tool
2) Reproductive age, cysts >5cm in diameter
3) Simple, unilocular cysts less than 10 cm in diameter confirmed by transvaginal ultrasonography are almost universally benign and may safely be followed without intervention regardless of age
-Possible complications: ovarian torsion or cyst rupture

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Describe the labs for adnexal masses

1) If concerned about malignancy, CA-125 may be helpful.
-Normal value <35
-If elevated in postmenopausal female with pelvic mass, suspicion increases for cancer.

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Describe screening for ovarian CA

1) USPSTF recommends against general population screening for ovarian cancer
2) Women with a family history of ovarian cancer or familial ovarian cancer syndromes are at higher risk… so screening is appropriate for these women
a) Recommend screening q 6months with CA 125 and TVUS beginning between 30-35yo OR 5 to 10 years earlier than the earliest age of first diagnosis of ovarian cancer in the family

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Describe ovarian size throughout a woman’s life

1) Normal ovary: 3.5 X 2 X 1.5 cm (premenopausal)
2) 2-5yrs post-menopause: 1.5 X 0.7 X 0.5 cm
*Postmenopausal ovary 2x the size of contralateral ovary is a suspicious finding

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Desc. what to look for on TVUS for malignancy

1) Cystic mass vs. solid
2) Smooth capsule vs. excrescences
3) Presence of internal septa or papillae

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Follicular cysts:
1) What are they? What is the main Sx?
2) When does it become clinically significant?
3) What should you do if it persists?

1) An ovarian follicle fails to rupture during follicular maturation and ovulation does not occur; Transient secondary amenorrhea
2) Becomes clinically significant if large enough to cause pain or persists beyond one menstrual interval
3) Another type of cyst or neoplasm should be suspected and further evaluated

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Define corpus luteum cysts

Diameter >3cm (cyst rather than corpus luteum)

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Differentiate b/t the 2 types of corpus luteum cysts

1) Slightly enlarged: corpus luteum may produce progesterone longer than the usual 14 days (*more common of the two types)
-Menstruation delayed
-Pelvic Exam: enlarged, tender, cystic or solid adnexal mass
2) Rapidly enlarging: luteal phase cyst with spontaneous hemorrhage (corpus hemorrhagicum)
-Typical patient: not taking OCPs, has regular periods, acute (severe) pain late in the luteal phase (rupture)

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Describe Theca Lutein Cysts (least common functional cysts)

1) Benign; associated with pregnancy, GTD, Ovarian Hyperstimulation Syndrome (OHSS)
-High levels of hCG
2) Usually bilateral
3) Regress spontaneously in most cases

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Benign Ovarian Neoplasms: In reproductive-age groups, about ___% of ovarian enlargements prove to be nonfunctional ovarian neoplasms

25%

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Differentiate the types of benign epithelial cell neoplasms

1) Epithelial Cell Tumors: largest class of ovarian neoplasm
2) Germ cell tumors: most common in reproductive-age women
3) Benign cystic teratoma or dermoid
4) Stromal cell tumors

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Benign Ovarian Neoplasms: Epithelial cell neoplasms; describe each of the following types:
1) Serous
2) Mucinous

1) Most common epithelial cell tumor- serous cystadenoma
-70% benign (20-30% malignant)
-Tx: surgery due to relatively high rate of malignancy
2) Mucinous
-15% malignancy rate
-Can become quite large and extend into abd cavity
Treatment: surgery

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Describe each of the following types and their Txs:
1) Endometrioid
2) Brenner Cell Tumor

1) Most are endometriomas (“chocolate cyst”)
Tx: Monitor
2) Uncommon. Usually Benign. Stroma and Fibrotic Tissue (solid).
Tx: Monitor

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Germ Cell Neoplasms:
1) Which of these is the most common tumor found in women of all ages?
2) How does this most common tumor usually present?

1) Benign cystic teratoma (dermoid cyst)
2) Usually asx, unilateral, mobile, nontender (10-20% bilateral)
-May contain hair and bone
-Increased risk of ovarian torsion (15%)
-Consider surgical removal

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Describe Stromal Cell Neoplasms

1) Solid
2) Functioning tumors (produce hormones) with malignant potential

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Stromal Cell Neoplasms: List and describe the 2 types

1) Granulosa theca cell tumors: Estrogen producing
2) Sertoli-Leydig cell tumors: Androgen producing (hirsutism or virilization)

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Benign stromal cell neoplasms: Ovarian fibromas
1) What are they the result of?
2) Do they secrete sex steroids? What do they look like?
3) What is the Tx?
4) What is Meigs syndrome?

1) Collagen production by spindle cells
2) Does not secrete sex steroids; small, solid tumor, occasionally with ascites
3) Surgery
4) Ovarian fibroma + ascites + right pleural effusion

Describe the basics of management for premenopausal adnexal masses

Suspect benign (but ASCITES almost always cancer)

Describe how to Tx postmenopausal adnexal masses

TVUS and serum tumor markers (CA-125, HE4)

List and describe the 4 primary stages of ovarian cancers

1) Stage I: Tumor Limited to Ovaries (one or both) 2) Stage II: Tumor involving one or both ovaries with pelvic extension or primary peritoneal cancer 3) Stage III: Tumor involving one or both ovaries with peritoneal implants outside the pelvis and/or positive retroperitoneal nodes 4) Stage IV: Tumor involving one or both ovaries with distant metastases

1) 10% of seemingly benign epithelial cell tumor have some neoplasia; these are called what? 2) What do 20% of these show? 3) What is the Tx?

1) Borderline malignancies 2) 20% show spread beyond the ovary 3) Tx: Unilateral oophorectomy and follow up if trying to preserve fertility

Epithelial Cell Ovarian Carcinoma: 1) How rare or common is it? 2) What is the most common subtype? Describe this type

1) Approximately 90% of all ovarian malignancies 2) Malignant epithelial serous tumors most common -Multiloculated -Calcified laminated structures (psammoma bodies)

Epithelial Cell Ovarian Carcinomas: 1) Describe the prevalence of Malignant mucinous epithelial tumors. What are they assoc. with? 2) Describe Heredity Epithelial Ovarian Cancer

1) 1/3 of all tumors; only 5% cancerous -Assoc. w. pseudomyxoma peritonei 2) 5-10%; BRCA1&2, Lynch

Germ Cell Tumors: Describe these

1) Most common ovarian cancers in women <20 y/o 2) May be functional (hCG or AFP)

Germ Cell Tumors: Describe Dysgerminomas

1) Usually unilateral and most common type of germ cell tumor 2) Radiosensitive and chemosensitive 3) 5-year survival rate is 90-95%

Germ Cell Tumors: Describe Immature Teratomas

1) Malignant counterpart of benign cystic teratomas (dermoid) 2) Usually unilateral 3) Rapid growth 4) Good prognosis with chemotherapy

Rare Germ Cell Tumors: 1) Which produces AFP only? 2) Which produces AFP and hCG? 3) What is the 5 year survival rate? 4) What is the Tx?

1) Endodermal Sinus Tumor 2) Embryonal Cell Carcinomas 3) More than 70% 4) Surgical resection of ovary + chemotherapy

Gonadal Stromal Cell Tumors: List and describe the 2 kinds

1) Granulosa Cell Tumor -Secrete large amounts of estrogen -May initially present with bleeding from endometrial hyperplasia 2) Sertoli-Leydig Tumors -Testosterone-secreting -Hirsutism, virilization and adnexal mass

Gonadal Stromal Cell Tumors: "Functioning Tumors”; usually ________

benign

Ovarian tumors: Malignant Mesodermal Sarcomas (carcinosarcomas): Describe these

1) Aggressive 2) Usually dx late 3) Poor survival rate

Cancer Metastatic to the Ovary: Describe Krukenberg tumors

1) Ovarian tumor metastatic from other sites -GI tract and Breast most common 2) Consider removal of ovary if treated for GI or breast cancer

Uterine Tube Disease: What are some common problems?

1) Ectopic pregnancy 2) Salpingitis 3) Hydrosalpix 4) Tubo-ovarian abscess 5) Endometriosis

List and describe 2 Benign Diseases of the Uterine Tube and Mesosalpinx

1) **Para-ovarian Cysts:** Develop in the mesosalpinx 2) **Hydatid Cysts of Morgagni:** Can contribute to infertility

Carcinoma of the Uterine Tube: Describe Primary Uterine Tube Carcinomas

1) Usually adenocarcinoma (sometimes have profuse discharge) 2) 2/3 postmenopausal 3) Usually advanced by the time sxs diagnosed 4) Staging similar to ovarian CA 5) 5-year survival rate is 35-45%

Management of Ovarian and Uterine Tube Cancers: 1) Describe Cytoreductive surgery 2) What should you do if there's recurrence after chemo?

1) “Tumor Debulking”: Goal to reduce tumor to less than 1cm in size 2) Other chemotherapeutic agents may be used to prevent recurrence

Management of Ovarian and Uterine Tube Cancers: Is radiation useful?

Limited role

Ovarian Cancer: Describe the Prognosis

Approximately 3/4 women alive 1 year after diagnosis 5-year survival rate: 46%

Ovarian Cancer: Describe the follow up

1) Clinical history and examination 2) Various imaging studies (U/S and/or CT) -Epithelial Cell Tumors: CA-125

Define menopause and perimenopause

1) Menopause: Permanent cessation of menses after a significant decrease in ovarian estrogen production *12 consecutive months with no menstrual bleeding* 2) Perimenopause: Estrogen production may fluctuate unpredictably.

How many ooctyes do you have at: 1) Birth 2) Puberty 3) Ages 30-35

1) 1-2 million oocytes 2) 400,000 oocytes 3) 100,000

1) Follicular Maturation is stimulated by what 2 things? 2) When do the oocytes get less responsive to these? 3) What is the avg age of menopause?

1) FSH and LH 2) Oocytes less responsive with age 3) 51.5

1) What is the primary estrogen hormone? 2) What converts into to this primary hormone? 3) What do high levels of this primary hormone promote?

1) Estrone is the primary estrogen hormone 2) Androstenedione converts to estrone 3) Endometrial proliferation

1) Menstrual Cycle Alterations: What are they related to? 2) What remains constant? 3) What increases?

1) Related to changes in the follicular phase 2) Luteal phase remains constant at 14 days 3) FSH increases

Menopause S/Sx: What causes hot flashes?

Vasomotor Instability Theory: possible declining estradiol and hypothalamic sensitivity

1) What are some risks for bone demineralization? 2) What is located in osteoblasts?

1) Decreased estrogen and low BMI 2) Estrogen receptors in osteoblasts

Osteoporosis: 1) What tool assesses Fx risk? 2) What scan should you use to base your Tx off of? 3) What should you encourage?

1) FRAX tool 2) DEXA scan 3) Encourage Calcium 1200mg/Vitamin D 800 IU to protect bones and DEXA scans to evaluate bone density.

What are some risks of Primary Ovarian Insufficiency?

-Genetics -Autoimmune -Smoking -Alkylating Cancer chemotherapy -Hysterectomy

Describe the several types of estrogen

1) Oral, Transdermal, Transbuccal, Transvaginal, Intramuscular and Topical -IM unpredictable -Oral altered through the liver