WH: L13 Ovarian and Adnexal Disorders

Premenarchal Ovary

non palpable

Reproductive Ovary

palpable about 50% of the time

Perimenopausal Ovary

Residual functional cysts

Postmenopausal Ovary

- majority is non palpable

- palpable enlargement needs evaluation

Which imaging is the primary component of ovarian evaluation

Pelvic US

Helpful ovarian cancer biomarker

Cancer antigen 125 (CA-125)

Hormone studies

- total testosterone

- LH:FSH ratio

- FSH and estradiol

- beta-hCG

Which hormone study is elevated with hyperandrogenism?

Total testosterone

Which hormone study is elevated with PCOS

LH:FSH ratio

What is laparoscopy a definitive dx for?

- salpingitis

- tubo-ovarian abscess

- ovarian torsion

Functional Ovarian Cysts

- not neoplasms

- arise from normal ovarian function

- most resolve spontaneously within 2 menstrual cycles

Functional Ovarian Cysts 3 Types

1. follicular cysts

2. corpus luteum cyst

3. theca lutein cyst

Functional Ovarian Cyst Most common

Follicular Cyst

Follicular Cyst

- occurs when ovarian follicle fails to rupture during follicular maturation

- continues to enlarge and fill with fluid rich in estrogen

How does a Follicular Cyst affect the follicular phase?

Lengthens

When are Follicular Cyst clinically significant?

Only when it causes pain or persists beyond one menstrual interval

Follicular Cyst sx

- transient secondary amenorrhea

- mild/moderate U/L lower abdominal pain

- irregular bleeding

- U/L tenderness

- palpable, mobile and cystic mass

Follicular Cyst dx

- Pelvic US: smooth, thin walled, unilocular

- rule out pregnancy with HCG

Follicular Cyst tx

- most resolve spontaneously within 6 wks

- analgesics if rupture

- OCPs

How do OCPs effect Follicular Cysts?

suppresses development of new cysts

Corpus Luteum Cyst

- fails to degenerate after ovulation

- > 3cm

- luteal phase

- progesterone-dominant

- mc cyst type in perimenopausal women

Corpus Luteum Cyst: 2 variations

- slightly enlarged corpus luteum

- luteal phase cyst ("Corpus hemorrhagicum")

How does a slightly enlarged corpus luteum effect menstruation?

Delays it from days to several weeks

Which Corpus Luteum Cyst is less common?

Luteal phase cyst/Corpus hemorrhagicum

What is a concern with Corpus hemorrhagicum?

Can cause a spontaneous hemorrhage

Typical patient profile with Corpus hemorrhagicum

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

Corpus Luteum Cyst sx

- delayed or missed menstrual period

- ipsilateral pelvic pain (dull/LQ)

- anlarged, tender, cystic or solid adnexal mass

- thicker walled

Which finding on US is concerning for hemorrhage with Corpus Luteum Cyst?

- Internal debris

- "ring of fire"

What should always be ordered to rule out with Corpus Luteum Cyst?

Beta-hCG to rule out ectopic pregnancy

slightly enlarged corpus luteum tx

- mild analgesia and reassurance

- recurrent: cyclic contraceptive therapy

- repeat US after 6wks

- if >10cm or in postmenopausal: surgical intervention

Corpus hemorrhagicum tx

- often self limiting

- surgical resection of bleeding cyst

- recurrent hemorrhagic: consider anticoagulant medications

Theca Lutein Cyst

overstimulation from high hCG levels or extreme sensitivity to hCG

What is Theca Lutein Cyst often seen in?

molar pregnancy, multiple gestation, fertility tx

Theca Lutein Cyst sx

- often asymptomatic

- thyroid dysfunction may occur

- preclampsia

Theca Lutein Cyst imaging

B/L, multilocular, large ovarian cysts "soap bubble" appearance

Theca Lutein Cyst tx

- gradually resolves weeks-mo after hCG is eliminated

- surgery if torsion occurs

Benign Ovarian Neoplasma

- 90% of ovarian neoplasms

- 25% or malignant in postmenopausal women

Benign Ovarian Neoplasma sx

- asymptomatic

- blating

- abdominal/pelvic/back pain

- urinary sx

- GI complaints

- palpable ovarian mass (U/L>B/L)

Benign Ovarian Neoplasma tx: if premenopausal, asymptomatic, mobile, or U/L simple cystic mass < 10cm

- observe for 4-6 weeks; most resolve spontaneously

- if longer/unchanged, surgical evaluation needed

How are Benign Ovarian Neoplasma categorized?

By cell type of origin

Benign Ovarian Neoplasma 3 Types

1. benign epithelial cell tumors

2. germ cell tumors

3. sex-cord stromal cell tumors

Which type of Benign Ovarian Neoplasma represents 2/3 of all ovarian tumors?

Benign Epithelial Cell Tumors

Benign Epithelial Cell Tumors

- >30yo (middle aged women)

- typical glandular epithelial cells

4 Types of Benign Epithelial Cell Tumors

- serous cystadenoma

- mucinous cystadenoma

- endometroid tumor

- brenner cell tumor

Which Benign Epithelial Cell Tumor is often B/L, presents at any age, and is most common?

Serous cystadenoma

Which Benign Epithelial Cell Tumors is characterized by a large size filled with mucin and has a median age onset of 50yo?

Mucinous cystadenoma

Which Benign Epithelial Cell Tumors is in reproductive or postmenopausal age, associated with endometriosis, and most often malignant?

Endometroid tumor

Which Benign Epithelial Cell Tumors is more common in older women but uncommon overall?

Brenner Cell tumor

Benign Germ Cell Neoplasms

- arise from primary germ cells

- young females 10-30yrs

- cystic teratoma/dermoid cysts

Benign Germ Cell Neoplasms sx

- abdominal enlargement, pain, and bloating

- often mobile

- non-tender adnexal mass

Benign Germ Cell Neoplasms dx

- can produce tumor markers: CA 19-9, LDH, ESR

- histology at surgical excision

What is the most common ovarian tumor in females 20-30yo

Cystic teratoma/dermoid cysts

Cystic teratoma/dermoid cysts

- multi-cystic mass

- can contain hair, teeth, and/or skin that is mixed into sebaceous, thick, sticky, and foul smelling material

Benign Germ Cell Neoplasms tx depend on

Dermoid size, patient sx, surgical risk, and suspicion for malignancy

Benign Germ Cell Neoplasms tx if expectant management chosen

Close F/U needed with serial USs to monitor for increase in size or characteristics associated with malignancy

Benign Stromal Cell Tumors (SCSTs) 2 types

1. granulose theca cell tumors

2. sertoli-leydig cell tumors

What do granulose theca cell tumors produce and cause?

estrogen; AUB

What do sertoli-leydig cell tumors produce and cuase?

Anrogens; virilization

When should you suspect a SCST?

if adnexal mass + endocrine effects

Benign Stromal Cell Tumors (SCSTs) dx

- labs: testosterone, estradiol, tumor marker

- imaging

- histologic dx

What do you do if your patient presents with an ovarian mass?

- rule out ectopic pregnancy

- perform US to characterize mass

- consider checking CA-125 tumor markers

- surgery if warranted

Ovarian Mass: Surgery for histology/removal ID

- US findings suggest mass could be malignant

- questionable dx

- risks associated with the mass

Ovarian Torsion

- complete or partial rotation of the ovary on its ligamentous support

- often results in partial or complete obstruction of its blood supply

- gynecologic surgical emergency

Adnexal Torsion

if fallopian tube twists along with ovary

Ovarian Torsion primary risk factor

Ovarian mass (especially if >5cm diameter)

Ovarian Torsion sx

- acute onset pelvic pain

- N/V

- hx of recent vigorous activities or a sudden increase in abdominal pressure

Ovarian Torsion dx

- Pelvic US with color flow doppler

- direct visualization of a rotated ovary at the time of surgical evaluation

Ovarian Torsion Pelvic US findings

- U/L enlarged ovary (>4-5cm)

- decreased or absent blood flow on doppler

- "whirlpool sign" of twisted vascular pedicle

- pain when scanning over adnexa

Whirlpool Sign

Ovarian Torsion tx: premenarchal + normal ovary

- oophoropexy + detorsion

Ovarian Torsion tx: premenopausal w/ non-malignant ovary

- detorsion and ovarian conservation

Ovarian Torsion tx: unsalvageable ovary, malignancy concern, or postmenopausal

Salpingo-oophorectomy

Salpingitis

- Inflammation of the fallopian tubes secondary to ascending infection

- part of larger PID infection

- major complication of gonorrhea/chlamydia

Salpingitis sx

- pelvic/abdominal pain

- fever

- discharge

- dysuria

- dyspareunia

- tenderness

Salpingitis definitive dx

laparoscopy w/ direct visualization of inflamed tubee

Salpingitis tx

- same as PID

- Ceftriaxone + Doxy + Metronidazole

Tubo-ovarian Abscess (TOA)

- Inflammatory mass involving the fallopian tube, ovary, and occasionally other adjacent pelvic organs

- common complication of PID

- frequently polymicrobial

Tubo-ovarian Abscess (TOA) sx

- acute lower abdominal pain

-fevers/chills

- vaginal discharte

Ruptured TOA

- abscess leaks inflammatory contents into abdominal cavity

- presents with acute abdomen and signs of sepsis

Tubo-ovarian Abscess (TOA) 1st line sx

Pelvic US

Tubo-ovarian Abscess (TOA) clinical dx

Inflammatory adnexal mass + meets dx criteria for PID

Tubo-ovarian Abscess (TOA) definitive dx

Only by direct visualization of the abscess during invasive surgery

Tubo-ovarian Abscess (TOA) tx: concern for ruptures of sx of sepsis

- immediate surgical exploration, laparotomy

- abx as soon as possible

Tubo-ovarian Abscess (TOA) tx: premenopausal, hemodynamically stable, and abscess

- Ceftriaxone 1g IG q24hr + Doxycycline 100mg PO/IV q12hr + Metronidazole 500mg PO/IV q12hr

Tubo-ovarian Abscess (TOA) if no improvement on abx, but not worsening tx

Minimally invasive drainage procedure

Tubo-ovarian Abscess (TOA) if clinically worsening on abx tx

surgical tx

Tubo-ovarian Abscess (TOA) tx: postmenopausal

surgical/laparotomy + abx

Polycystic Ovarian Syndrome (PCOS)

- mc cause of infertility

- mc cause of androgen excess and hirsutism

- ovulatory dysfunction and hyperandrogenism

Polycystic Ovarian Syndrome (PCOS) sx

- menstrual irregularity

- AUB/infertility

- hirsutism

- acne

- alopecia

- insulin resistance/obesity

- B/L enlarged, smooth, mobile ovaries

- acanthosis nigricans

What are women with PCOS at higher risk for?

Metabolic syndrome

Polycystic Ovarian Syndrome (PCOS) dx

- Rotterdam Criteria

- dx of exclusion

- "string of pearl" on TVUS

Rotterdam Criteria (2/3)

- irregular menses

- clinical and/or biochemical signs of hyperandrogenism

- polycystic ovaries on TVUS

Polycystic Ovarian Syndrome (PCOS) labs

- elevated total testosterone

- increase in LH/FSH ratio

- serum anti-mullerian hormone (AMH)

PCOS Hirsutism tx

COCP +/- spironolactone

PCOS acne tx

COCP +/- spironolactone

PCOS scalp hair loss

Minoxidil +/- spironolactone

PCOS DM II/CVD risk

- dietary and lifestyle changes

- weight loss medications

- DM meds as needed

PCOS tx (desire to conceive)

- Letrozole

- weight loss

- IVF

- Clomid, metformin

PCOS tx (no desire to conceive)

- COCP

- metformin

- IUD, intermittent progestin