Diseases and Disorders of the Ovaries

What is the space between the lateral pelvic wall and the cornu of the uterus?

adnexal space

What are the adnexal structures?

-Ovaries

-Fallopian tubes

-Upper portion of broad ligament and mesosalpinx

-Remnants of the embryonic Mullerian duct

What are the ovary characteristics of these stages? Palpable or nonpalpable?

premenarchal-

reproductive-

perimenopausal-

postmenopausal-

premenarchal- non palpable

reproductive- palpable, 50% of the time

perimenopausal- residual functional cysts

postmenopausal- majority non-palpable

What is the MC functional cyst?

follicular

What are the 3 types of functional ovarian cysts?

follicular, corpus luteum, and theca

What type of cyst occurs when the ovarian follicle fails to rupture during follicular maturation?

follicular

What effects does a follicular cyst have?

lengthening of the follicular phase

What is the primary hormone of a follicular cyst?

estrogen

How do follicular cysts present?

secondary amenorrhea, mild to moderate unilateral abd pain, with irregular bleeding

How will a follicular cyst appear on an US?

smooth, thin walled, and unilocular on ultrasound examination

What is the tx for follicular cysts?

Most resolve spontaneously within 6 week

OCP- suppress gonad stimulation, does NOT shrink them

What type of cyst occurs when a functional ovarian cyst fails to degenerate after ovulation?

corpus luteum cyst

What hormone is dominant for a corpus luteum cyst?

progesterone

What is a typical pt for a luteal phase cyst-- "corpus hemorrhagicum"?

NOT on OCP, has regular cycles, and acute pain late in luteal phase

How does a corpus luteum cyst present?

delayed or missed period, ipsilateral unilateral pelvic pain (dull)

How will a corpus luteum cyst show up on an US?

•Enlarged, tender, cystic or solid adnexal mass

•thicker-walled with peripheral vascularity

What is the least common functional cyst?

theca lutein

What is the tx for corpus luteum cyst?

mild analgesia and reassurance

What functional cyst is associated with pregnancy and is typically bilateral and occurs due to excess BHcg stimulation?

theca lutein

What functional cyst is rare but there is a risk for torsion or rupture?

theca lutein

90% of ovarian neoplasms are benign in ________________ women

reproductive age

25% are malignant in ________ women

postmenopausal

What age women is at higher risk for ovarian neoplasms?

older age

What is the tx for a premenopausal women with a benign ovarian neoplasm?

<7.5cm

observe 4-6wks

-- most spontaneously resolve, if larger excise

What is the tx for a postmenopausal women with a benign ovarian neoplasm?

if asymp, unilateral, and normal CA-125--- follow with TVUS!!!

if symp -- surgical exicison!

What does a mass <5cm suggest?

functional cyst

What makes up the largest class of ovarian neoplasms- epithelial?

-Serous

-Mucinous

-Endometrioid

"SEM"

What makes up the germ cell tumor line of ovarian neoplasms?

-Benign Cystic Teratoma or

Dermoid

*MC ovarian neoplasm in reproductive age women

-Dysgerminoma

-Endodermal sinus (yolk sac)

-Choriocarcinoma

What are the stromal cell tumors?

-Granulosa theca

-Sertoli-Leydig (arrhenoblastoma)

-Lipid cell fibroma

What is the MC epithelial cell tumor that is often bilateral and has to be surgically removed bc of high malignancy rate?

serous cystadenoma

What group of neoplasms is the largest and represents 2/3 of ovarian tumors?

benign epithelial cell neoplasms

What is the tx for serous cystadenoma?

older pts and done child bearing- BSO and TAH

small tumor young pts to preserve ovaries- cystectomy

large tumor in young pts- oophorectomy

What is the 2nd MC epithelial tumor that is LARGE?

mucinous cystadenoma

What will you see on an US with suspected mucinous cystadenoma?

multilocular septations

What epithelial cell neoplasm is a cystic tumor that is well differentiated with endometrial glandular tissue and likely malignant?

endometroid tumor

What neoplasms arise from primary germ cells that can contain hair or bone?

germ cell neoplasms

What is the MC tumor found in women of all ages?

benign cystic teratoma aka dermoid

What is an uncommon variant of germ cell tumor that has functioning thyroid tissue that can cause hyperthyroidism?

struma ovarii

What is the presentation of benign cystic teratoma or dermoid cyst?

asymp, pain due to rapidly enlarging mass, unilateral, mobile, and nontender

What are the diagnostic findings for a benign cystic teratoma/dermoid cyst?

solid and cystic- US

high fat content on CT, high ovarian torsion rate due to bouyancy

What type of neoplasms are benign solid tumors that present with sign and symptoms of precocious puberty?

benign stromal cell

What type of benign stromal cell neoplasm develops with primarily female cell type and produces estrogen --- malignant potential?

granulosa thecal cell

What type of benign stromal cell neoplasm develops into male gonadal tissue, produces androgenic components, and has malignant potential?

sertoli leydig

What is the primary hormone production of granulosa theca cell tumros?

estrogen

What is the primary hormone production of sertoli-leydig cell tumors?

androgenic

What type of benign stromal cell neoplasm is a result of collagen production by spindle cells and is MC during middle age with NO secretion of sex steroids?

ovarian fibroma

What type of benign stromal cell neoplasm can cause thelarche and very early vaginal bleeding?

granulosa thecal cell

What type of benign stromal cell can contribute to hirsutism or virilizing symptoms?

sertoli

What age is MC for ovarian fibroma?

middle age

What has the highest mortality rate of gynecologic malignancies bc it is difficult to diagnose?

ovarian cancer

What is the MC type of ovarian cancer?

epithelial cell

What are the RFs associated with ovarian cancer?

•Risk increases with age until age 70

•

•Nulliparity

•

•Early menarche

•

•Late menopause

•

•Family history: 5% risk if 1st degree

•

•Primary infertility

•Endometriosis

•

•Race/Ethnicity

•

•BRCA1 and BRCA-2 mutations

-BRCA1 40%

-BRCA2 15%

•HNPCC, formerly Lynch Syndrome

What are the protective factors related to ovarian cancer?

•Use of OCPs (~50% risk reduction w. 10 yrs of use)- decreases # of ovulatory cycles

•Parity, high parity

•Tubal ligation

•BSO

•TAH

•Breastfeeding

What are the sx associated with ovarian cancer?

distention, ascites

bloating or fullness

early satiety

abd or pelvic pain

back pain

What are the labs and diagnostics for ovarian cancer?

•Labs

-CA125, AFP, estrogen, testosterone, beta-HCG

•Imaging

-TVUS for high risk

If a post menopausal pt has a normal CA-126 level does that mean they are cancer free?

no!

What are the 3 histologic classifications of ovarian cancer?

1. Malignant epithelial cell tumors (MC)

2. Germ cell tumor

3. Stromal cell tumor

What type of ovarian carcinoma:

MC! arises from a benign precursor and 30% present bilateral

malignant epithelial serous tumors

What type of ovarian carcinoma:

largest!!!!

malignant mucinous epithelial tumor

What type of ovarian carcinoma:

associated with endometriosis and or endometrial cancer

endometrioid tumor

What is the MC ovarian cancer in women <20-30yo?

germ cell tumors

What are the MC germ cell malignancies?

dysgerminoma and immature teratoma

What is the MC germ cell tumor in pts with gonadal dysgenesis (turner syndrome)?

dysgerminoma

What germ cell tumor is found in women <25yo often unilateral and rapidly growing?

immature teratoma

What type of germ cell tumor:

uncommon, presents in childhood and adolescence, produces AFP!, and treated via oophorectomy with chemo

endodermal sinus tumor

What type of germ cell tumor:

produces both AFP and bhcg

embryonal cell carcinoma

What is the postmenopausal tx for a pt with malignant granulosa cell tumors?

BSO and TAH

What is the younger age tx for a pt with malignant granulosa cell tumors?

unilateral oophorectomy

What type of surgery can be done for reducing ovarian cancer tumor masses to <1cm-- allowing for radiation and chemo to be more effective?

debulking surgery or cytoreductive surgery

What are the 1st line chemo agents for ovarian cancer?

taxanes combined iwth carboplatin or cisplatin

What occurs with ?Complete or partial rotation of the ovary on its ligamentous support

ovarian torsion

What is the MC gynecologic surgical emergencies and may affect females of all ages?

ovarian torsion

What type of torsion occurs when the The fallopian tube often twists along with the ovary?

adnexal torsion

What is the primary RF associated with ovarian torsion

ovarian mass, esp. >5cm in diameter

What is the presentation of ovarian torsion?

acute onset of pelvic pain with N/V, adnexal mass and pt most likely just got back from strenuous activity

What is the mainstay for ovarian torsion dx?

pelvic US with color flow doppler

What is the definitive dx for ovarian tosion?

direct visualization of a rotated ovary at the time of surgical eval

What is the tx for a Premenarchal pt with ovarian torsion and a normal ovary?

•oophoropexy in addition to detorsion

What is the tx for ovarian torsion in a Premenopausal patients with nonmalignant ovary?

detorsion and ovarian conservationdetorsion and ovarian conservation

What is the tx for ovarian torsion in a Necrotic ovary, ovarian mass suspicious for malignancy, or postmenopausal?

salpingo-oophorectomy

What is the term for excess terminal hair in a male pattern distribution due to excess exposure to androgens?

hirsutism

What is the term for masculinization of a women that is associated with increases testosterone?

virilization

What is the MC pathologic cause of hirsutism and virilization?

PCOS

What is a weak androgen secreted mainly by adrenal glands that is a reliable measure of androgen production?

DHEA

What is a weak androgen secreted by both adrenal and ovaries?

androstenedione

What is the potent androgen secreted by adrenal and ovaries that is produced in adipose tissue from conversion of androstenedione?

testosterone

What is the MC adrenal disorder that can increase androgen production?

congenital adrenal hyperplasia

What is an inherited defect in cortisol formation that causes low levels of cortisol to stimulate production of ACTH?

congenital adrenal hyperplasia (CAH)

What does congenital adrenal hyperplasia (CAH) cause?

decreased production of:

Glucocorticoids (cortisol): regulates blood pressure, body’s response to illness or stress, maintaining blood sugar and energy

Mineralocorticoid (aldosterone): regulates sodium and potassium levels

What are most cases of CAH due to that manifests in infancy as virilization and adrenal insufficiency?

21-hydroxylase deficiency

What hormones are elevated in CAH?

17-OH progesterone and DHEA-S

What in CAH will present as abnormal or ambiguous genitalia: enlarged clitoris or genitals that look like male at birth or in the womb; hirsutism in later life?

virilization

What in CAH can develop a few day to week in life with V/D, hypovolemia, hyponatremia, hyperkalemia, hypoglycemia, and or hypotension?

adrenal crisis

What is an adrenal androgen excess disorder that presents with truncal obesity, moonlike facies, glucose intolerance and skin thinning/striae?

cushings syndrom

What adrenal androgen excess disorder occurs due to an oversecreting tumor- severe acne, amenorrhea, and virilization with DHEA-S elevated?

adrenal neoplasm

What is the dx for adrenal neoplasms?

CT or MRI of adrenal

What is the tx for adrenal neoplasms?

surgical removal

What is the MC cause of infertility in women?

PCOS

What is the MCC of androgen excess and hirsutism in women?

PCOS

What is the clinical presentation of PCOS?

•Bilateral enlarged, smooth, mobile ovaries

•Acanthosis nigricans

•Menstrual Irregularity

•Abnormal uterine bleeding

•Hirsutism

•Acne

•Alopecia

•Insulin resistance

•Obesity

•Virilization

•Infertility