Gyno Chapter 44 - Ovary Pathologies

Gyno 1

Ovaries

paired, almond shaped organs situated on each side of the uterus

T or F: the ovaries are fixed in location and are not influenced by uterine location

False; ovaries are influenced by uterine location and ligament attachments

Following a hysterectomy, ovaries are more ______ and ______ to the vaginal cuff

medially; superior

Normal sonographic appearance of ovaries

homogeneous

may exhibit central more echogenic medulla

small anechoic or cystic follicles may be seen peripherally

varies with age and menstrual cycle

Graafian follicle normal size

2.0 to 2.5 cm at time of ovulation

T or F: a young will potentially have more follicles on their ovaries

true

The ______ _______ sustains a first trimester pregnancy until the _______ develops

corpus luteum; placenta

Normal sonographic appearance of a corpus luteum

may be identified as a small hypoechoic or isoechoic structure peripherally within the ovary

may appear irregular with echogenic walls and contain low-level echoes

less frequent appearances include a typical “ring” color flow Doppler pattern around the wall of an isoechoic corpus luteum 

multiple small, punctate, echogenic foci

very small (1-2 mm)

In absence of fertilization, _____ _______ begins to undergo involutional changes on _________ days 8 or 9

corpus luteum; postovulatory

Postmenopausal ovaries:

atrophy and follicles disappear

may be difficult to visualize

Ovarian volume formula

0.523 x length x width x height

Mean ovarian volume

9.8 plus or minus 5.8 cc

Abnormal ovarian volume for a postmenopausal patient

> 8 cc

Postmenopausal ovarian volume more than twice of the opposite ovary is considered ________ regardless of the _______ _____

abnormal; actual size

Main ovarian function

mature oocytes until ovulation

Functional cysts may produce:

discomfort

delayed menses

Postmenopausal cysts greater than ____ cm and for those containing internal _______ or solid _______ may be malignant

5; septations; nodules

Majority of ovarian masses are _______ cysts and are _______

simple; benign

Complex mass

any simple cyst that hemorrhages may appear complex

Peak fertile years, solid tumors are:

1 in 15 malignant

After 40, solid tumors are:

1 in 3 malignant

The more ______ the tumor, the more likely it is to be malignant, especially associated with ______

complex; ascites

Solid tumors clinical signs

may be one or multiple cysts

¼ are bilateral

most occur over 40

can be large in size and often fill the pelvic cavity

Solid tumor differential considerations

pedunculated

dermoid

fibroma

granulosa

fibroid

cell tumor

metastasis

TOA

ovarian torsion

hemorrhagic cysts

ectopic pregnancy

Solid adnexal tumors are:

often difficult to diagnose because the normal ovarian size varies

When a ______ mass is identified, try to identify its connection with the ______

solid; uterus

Patients with a normal menstrual cycle are best scanned in the first ___ days of the cycle to avoid confusion with normal changes in ________ blood flow because high _______ flow occurs in the _______ phase

10; intraovarian; diastolic; luteal

An RI index below ___ and a PI index below ___ may be considered malignant

0.4; 1

Abnormal waveforms can be seen in:

inflammatory masses

metabolically active masses

ectopic pregnancy

corpus luteum cysts

Functional cysts result from _______ function of the ovary

normal

Functional cyst measurements

most measure < 5 cm

Follicular cyst

occurs when the mature follicle fails to ovulate or involute

Follicular cysts are usually _______ and regress ________

unilateral; spontaneously

Follicular cyst measurements

usually 2 cm but can be as large as 20 cm

Follicular cyst clinical features

asymptomatic to dull pain

adnexal pressure

abnormal ovarian function

torsion of the ovary

Corpus luteum cyst

results from failure of absorption of excess bleeding into corpus luteum

A corpus luteum cyst is a sign of a normal:

early pregnancy

Corpus luteum measurements

usually < 4 cm

Corpus luteum sonographic sign

Ring of fire

Clinical and sonographic features of a corpus luteum cyst

irregular menstrual cycle

pain

mimics an ectopic pregnancy

cystic type lesion

more vascularity than a follicular cyst

Theca-lutein cysts

largest of the functional cysts

bilateral, multiloculated cysts

What does a theca-lutein cyst stem from?

Ovarian hyperstimulation by high levels of hCG

Clinical presentation of a theca-lutein cyst

nausea and vomitting

seen in infertility patients

“grape clusters”

OHS

Ovarian Hyperstimulation syndrome

Mild form of OHS

pelvic discomfort

no significant weight gain

ovaries are enlarged but measure <5 cm in diameter

OHS severe form

severe pelvic pain

abdominal distention

ovaries > 10 cm

ascites

pleural effusions

numerous large, thin-walled cysts throughout the periphery of ovary

PCOS

Polycystic ovary syndrome

What is PCOS

an endocrine disorder associated with chronic anovulation

infertility

amenorrhea

obesity

hirsutism (excessive hair growth)

Age for PCOS

occurs in late teens through 20s

Sono signs for PCOS

“string of pearls”

ovaries may appear enlarged with echogenic stroma

increased numbers of follicles bilaterally

ALSO increase in LH, FSH, and testosterone 

Ovarian Remnant Syndrome

cystic mass may be seen in patient with a history of a bilateral oophorectomy

Peritoneal Inclusion Cyst

formed when adhesions trap peritoneal fluid around the ovaries and create a large adnexal mass; associated with PID, abdominal pain, and endometriosis

Paraovarian cysts

accounts for approx. 10% of adnexal masses

located in the broad ligament

usually simple

can bleed or torse

have thin, deformable walls that are not surrounded by ovarian stroma

Paraovarian cysts can become large and extend into the upper _______

abdomen

Why does the size of a paraovarian cyst not change with the hormone cycle?

It is outside of the ovary

Fluid collections in adhesions

can create cystic structures of odd shapes throughout the abdomen

Omental cysts

tend to be higher in the abdomen

Urachal cysts

midline in the anterior abdominal wall peritoneum above the bladder

Benign cyst in a fetus

small simple cyst (1-7 mm)

occur in newborn girls because of the stimulation of maternal hormones

Benign cysts in premenarchal girls

small follicles < 9mm are common

_______ ovaries in postmenopausal women are of concern

palpable

Small simple cyst size in postmenopausal women

up to 3 cm, seen in approx. 15% of patients

_____% to ______% of ovarian malignancies are ______ in origin

85;90; epithelial

Endometriosis

common condition where functioning endometrial tissue is outside of the uterus

Endometriosis is found on:

ovaries

external surface of uterus

scattered over peritoneum

fallopian tube

broad ligament

CDS

bladder

Which form of endometriosis is more common?

diffuse

Endometrial tissue cyclically ______ and _______

bleeds and proliferates

In its diffuse form, _________ leads to disorganization of pelvic anatomy with an appearance similar to ___ or chronic ______ pregnancy

endometriosis; PID; ectopic

What is localized endometriosis called?

endometrioma

Another name for an endometrioma

chocolate cyst

Sonographic appearance of an endometrioma

well defined, unilocular or multilocular

predominantly cystic containing diffuse homogeneous, low-level internal echoes

occasionally fluid-filled level can be seen

MORE COMMON IN THE LEFT OVARY

Ovarian torsion usually occurs in

childhood and adolescence

With ovarian torsion, the ovary is usually measuring at

> 4 cm

What does doppler look like in ovarian torsion?

little to no blood flow

Ovarian torsion accounts for ___% of gynecologic emergencies

3

Clinical presentation of ovarian torsion

acute, unilateral pain

intermittent pain may precede the acute pain by weeks

fever, nausea and vomitting

palpable mass > 50% of patients

the RIGHT ovary is 3x MORE LIKELY than the left

Telltale sign of ovarian torsion

whirlpool sign

Neoplasm

an overgrowth of tissue

Only ___% of ovarian cysts <___ cm are malignant

3; 5

Cysts > ___ cm are recommended for surgical ______

5; removal

Sono appearance of ovarian neoplasms

doppler shows low-resistive patterns

extension beyond the ovary into the omentum or peritoneum and liver metastasis should be evaluated

malignant ascites may be present

unilocular or thinly septated cysts more likely to be benign; thicker walls are malignant

any change in ovarian echogenicity or volume of more than 20 ml should be considered suspicious

Ovarian carcinoma often detected by:

physical examination

laboratory

imaging findings

Ovarian cancer is the ______ leading cause of cancer death

fourth

Ovarian cancer is the leading cause of death from gynecologic malignancy (_____) in the US

25%

____ of ovarian malignancies occur in women between ages ____ and _____

60%; 40; 60

About _____ of cases involve women over ____ with the risk of cancer _____ with age

80%; 60; increasing

At the time of ______ detection, _____ of women present with stage ____

initial; 50%; 3

CA-125 is ______ in some patients, but ______ as a screening test; inability to detect ____ cases of ______ cancer

helpful; disappointing; many; ovarian

Ovarian carcinoma can present as:

complex

cystic

solid mass

“more likely predominantly cystic”

as many as 20% are bilateral

What are signs of a mass being malignant?

size

age of the patient

ultrasound characteristics

in long > 10 cm more likely  to be malignant

patient history

appears primarily related to genetic mutations in BRCA1 and BRAC2 genes

nulliparity

infertility

uninterrupted ovulation

late menopause

Clinical presentation of ovarian carcinoma

vague abdominal pain

swelling (bloating)

indigestion

frequent urination

constipation

weight change (ascites)

Serum CA-125 is elevated in over ____ of epithelial ovarian cancers

80%

____ to _____ of all ovarian neoplasms and _____ to ____ of all ovarian malignancies are epithelial tumors

65%;75%;80%;90%

Epithelial tumors are the ones that often fill the ____ and extend into the ______

pelvis; abdomen

Two most common types of epithelial tumors

serous and mucinous

Mucinous cystadenoma

type of epithelial tumor lined by mucinous elements of the endocervix and bowel; benign; ages 13-45; MOST COMMON CYSTIC TUMOR

Mucinous cystadenoma size

usually unilateral; can measure up to 15-30 cm and weigh up to 100 lbs

Mucinous cystadenomas are filled with

sticky, gelatin-like material

Clinical features of mucinous cystadenomas

pressure

pain

increased abdominal girth

ALSO HAVE INTERNAL ECHOES

Mucinous cystadenoCARCInoma

usually bilateral and malignant

10% occur in menopausal women

can also become very large and are more likely to rupture