Ovarian

Ovarian Cysts

Functional Cysts

  • Follicular cysts (MC) associated with ↑ estrogen

    • When follicle does not rupture and release egg

  • Corpus luteum cysts associated with ↑ progesterone only BC & pregnancy

    • Produces progesterone ➔ delayed menses

    • US shows ovarian cysts with variably thick walls and ↑ vascularity

  • Theca lutein cysts associated with ↑ LH/FSH and HCG

    • Multiple gestations and gestational trophoblastic disease

    • US shows multiple cysts with thin walls

Nonfunctional cysts

  • Chocolate - menstrual debris

  • Dermoid - somatic tissue (hair/teeth/glands)

  • Cystadenoma - serous (watery) or mucinous (gelatinous)

  • Malignant - type of ovarian cancer

  • SSX: Asx or palpable adnexal mass

  • SSX of rupture: Sudden onset of unilateral lower abd pain typically after physical activity

    • Can ➔ torsion (if >5cm) OR rupture ➔ hypovolemic shock

    • ± N/V, spotting

  • DX

    • HCG to r/o ectopic

    • US to r/o torsion

      • Rupture: Rectouterine pouch fluid (pouch of Douglas) ± visualized mass

        • Mass and fluid in pouch can be seen in ruptured ectopic

    • CT with contrast if not pregnant and US not helpful

    • Must r/o ovarian cancer, especially if pre or postmenopausal

  • TX

    • Cysts often resolve, NSAIDs for pain

    • Rupture and unstable ➔ emergency lap-exploration to stop bleeding, may need oophorectomy

    • Rupture and unstable ➔ analgesics and monitor for bleeding (hypotension, H&H)

Polycystic ovarian syndrome

  • Insulin insensitivity (causal or consequence) ➔ obesity/overweight, insulin insensitivity

  • PCOS ➔ ↑ risk of endometrial cancer and ovarian cancer

  • HPA axis problem: LH > FSH

    • ↑ LH ➔ ↑ androstenedione (androgen) ➔ peripheral estrogen ⊣ FSH

      • ↑ LH ⊣ LH surge ➔ anovulation/oligoovulation ➔ amenorrhea

    • ↑ androgens ➔ hirsutism, acne

  • DX

    • Clinical evidence and/or biochemical evidence of hyperandrogenism AND one year of abnormal menstruation

      • Hirsutism, acne, ♂ pattern baldness and/or

      • LH >> FSH ratio,↑ androstenedione ,↑ testosterone, ↓ sex hormone binding globulin

    • R/o Cushing, adrenal hyperplasia, hyperprolactinemia

      • US shows ovarian volume >10mL/multiple cystic follicles (string of pearls)

  • TX

    • Lifestyle (diet, exercise) most important

    • Dual oral contraceptives (same VTE risk)

      • If concern about estrogen exposure ➔ medroxyprogesterone or progestin IUD

      • Add anti-androgens (spironolactone > finasteride) at 6mo if refractory

    • If trying to get pregnant: Metformin or letrozole or clomiphene

Ovarian Cancer

  • Epithelial carcinoma (MC), germ cell tumors, sex cord/stromal tumors

  • Unopposed estrogen, PCOS, ➔ ↑ risk

  • Dual oral contraceptive is protective (estrogen opposed by progestin)

  • SSX

    • Mild and nonspecific sx

    • Adnexal mass ➔ bloating, non specific pelvic pain ("pants don't fit but losing weight")

    • Early satiety, ∆ urine

    • Spotting, postmenopausal bleeding (endometrial cancer > ovarian cancer)

      • Advanced/metastasis

        • Bowel obstruction, torsion, jaundice/ascites

        • ABD pain from omental caking, LN (supraclavicular/inguinal)

  • DX

    • Pelvic US (trans-abd and trans-vag)

      • Vascularization, irregularly thick septa with indistinct borders, free fluid consistent with ascites

    • Non-surgical biopsy and FNA should not be done (↑ risk of spreading)

    • CT evaluate for mets

    • ↑ tumor marker CA-125 (used for monitoring)

      • ↑ CA-125 premenopausal likely benign

      • ↑ CA-125 in postmenopausal ➔ ↑ concern for malignancy

        • CA-125 is also elevated in PID, pregnancy, endometriosis

  • TX is surgical staging with debulking with adjuvant chemo

    • Hysterectomy Bilateral salpingo oophorectomy

    • Omentectomy

    • Pelvic and paraaortic LN dissection

    • Peritoneal cytology

Torsion

  • Risk factors: MCC is ovarian mass (tumor/cysts >5cm), pregnancy

  • Ovary and fallopian tube twist around infundibulopelvic and ovarian ligament

  • ➔ ↓ outflow ➔ fallopian tube and ovary edema ➔ ↓ arterial blood supply ➔ ischemia ± necrosis

  • SSX

    • Sudden onset of unilateral lower abd pain typically after physical activity

    • ± N/V, spotting, palpable mass

  • DX

    • HCG to r/o ectopic

    • US: Edematous (enlarged) and heterogenous ovary with ↓ blood flow, thick fallopian tube, twisted pedicle

    • MRI > CT with contrast if US not helpful

  • TX - lap-exploration for any suspected ovarian torsion

    • Premenopausal: adnexal detorsion trying to save ovaries

    • Postmenopausal: salpingo-oophorectomy