Women's Health: Ovary & Adnexa

Ovarian Cyst

Fluid-filled sac within the ovaries that are most commonly related to ovulation, usually unilateral

-Common in reproductive years, most spontaneously resolve within a few weeks

-Presentation: most are asx but may be associated with abnormal uterine bleeding, dyspareunia, unilateral pelvic pain, mobile palpable cystic adnexal mass

-Dx: transvaginal US, beta-hCG to rule out pregnancy, and tumor markers if suspicious for malignancy

Supportive care

If an ovarian cyst is <8 cm in diameter, what is the treatment of choice?

-Repeat U/S after 1-2 menstrual cycles

Surgery

If an ovarian cyst is > 8cm in diameter, what is the treatment of choice?

Malignant

Cysts in postmenopausal women are considered to be what until proven otherwise?

Follicular Cyst

Most common type of ovarian cyst, which occurs when follicles fail to rupture and continue to grow

-Lengthening of the follicular phase

-Presentation: mild to moderate lower abdominal pain and alteration in menstrual intervals

-Imaging: smooth, thin-walled unilocular cyst

Corpus Luteal Cyst

Type of ovarian cyst that forms after the corpus luteum fails to degenerate after ovulation

-Presentation: Asymptomatic, pain and local tenderness, ovarian torsion or rupture and bleeding

-Imaging: Complex, thicker-walled with peripheral vascularity

Theca Lutein

Type of ovarian cyst associated with excess beta-hCG, which causes hyperplasia of theca interna cells

-Seen in hydatidiform male, hCG, and clomid use

-Presentation: usually bilateral, pelvic heaviness

CA-125

What tumor marker is associated with ovarian cancer?

Ruptured Cyst

Asymptomatic or sudden onset of unilateral, lower abdominal pain that is often sharp and ocal

-Often occurring during sexual activity or strenuous physical activity

-Presentation: abnormal uterine bleeding, unilateral pelvic pain or tenderness, mobile palpable cystic adnexal mass, and may have signs of hemodynamic compromise of massive bleeding

-Dx: TVUS (adnexal mass + pelvic fluid)

-Tx: expectant management

Cyst Rupture

An adnexal mass and pelvic fluid on transvaginal ultrasound should make you think of what diagnosis?

Hospitalization + fluids

What is the treatment of choice for ruptured ovarian cysts with significant hemoperitoneum?

Surgery, cystectomy

What is the treatment of choice for a patient who is hemodynamically unstable or with ongoing hemorrhage? What if they are premenopausal?

Ovarian Torsion

Complete or partial rotation of the ovary on the infundibulopelvic ligament, which can compromise ovarian blood flow and lead to infarction

-RF: presence of ovarian mass (MC), hx of prior torsion, and tubal ligation

-Presentation: sudden onset sharp, unilateral pelvic pain, N/V, abdominal tenderness or adnexal mass

-Dx: US with doppler

-Tx: laparoscopy with detorsion, salpingo-oophorectomy if necrotic

Laparoscopy

Normal blood flow on doppler US does not exclude ovarian torsion. What is the definitive diagnostic test?

PCOS

Condition characterized by bilateral cystic ovaries, insulin resistance, and hyperandrogenism

-MC cause of infertility, associated with an increased risk of metabolic syndrome and endometrial cancer

-Presentation: oligomenorrhea/amenorrhea, hirsutism, type 2 diabetes, obesity, hypertension, enlarged ovaries on bimanual exam, acanthosis nigricans

-Dx: elevated testosterone, LH/FSH > 3:1 (Rotterdam Criteria)

-Tx: lifestyle modifications, OCPs, anti-androgenic agents, infertility meds

Rotterdam Criteria

What is the criteria used to diagnosis PCOS?

-Must have 2/3: lab or clinical signs of hirsutism/acne/baldness, amenorrhea or oligomenorrhea, and cystic ovaries on US (string of pearls sign)

Spironolactone

If PCOS symptoms persist after 6 months on OCPs, what anti-androgenic medication can be added?

Clomiphene

What medication is used for infertility in PCOS?

Ovarian Cancer

2nd MC gynecological cancer, associated with the highest mortality rate

-RF: increased number of ovulatory cycles, family hx, BRCA, Lynch Syndrome

-Protective Factors: hormonal contraception, tubal ligation, and hysterectomy

-Presentation: Rarely symptomatic until late in the disease course with abdominal fullness, weight loss, back/abdominal pain, early satiety, constipation or bowel obstruction, irregular menses, menorrhagia, postmenopausal bleeding, ascites, palpable abdominal or ovarian mass

-Dx: Pelvic U/S is initial diagnostic of choice, CA-125 levels, staging CT

-Tx: depends on stage

CA-125

What tumor marker is used to monitor treatment progress in ovarian cancer?

Surgical removal

What is the treatment of choice for stage I ovarian cancer?

Surgery + chemo

What is the treatment of choice for stage II-IV ovarian cancer?

Benign

Are the following ovarian neoplasms benign or malignant?

-Epithelial cell → serous cystadenoma, mucinous, endometrioid

-Stromal cell → granulosa thecal, sertoli-leydig

-Germ cell → teratoma/dermoid cyst

Malignant

Are the following ovarian neoplasms benign or malignant?

-Epithelial cell tumors → 90% in women > 50 years old, mesothelial cell origin

-Germ cell tumors → MC in women < 20 years old, produces hormones

-Stromal cell tumors → functional tumors that secrete sex steroids

Granulosa Cell

What type of tumors secrete estrogen, which can pose a higher risk in post-menopausal women?

HCG + AFP

What tumor markers should be monitored in germ cell tumors?