Ovarian Conditions

It is not uncommon to develop cystic masses on the ovaries.
– In premenopausal women, most ovarian masses are benign.
– The incidence of ovarian cancer increases with age, so postmenopausal women are at a higher risk of malignancy
– There are both non-neoplastic and neoplastic types of cysts which can occur naturally or be pathological:

 a) Non-Neoplastic Cysts:

  •  Physiological ➔ These develop as part of the menstrual cycle.
    – They are considered physiological and usually self-resolve over 2-3 menstrual cycles. They include:
    i) Follicular cysts –> these occur when the dominant follicle does not rupture releasing the egg cell
    ii) Corpus luteum cyst –> occurs when the corpus luteum fails to breakdown but persists in the ovary

 

  • Pathological ➔ This can be seen in Polycystic ovary syndrome (PCOS)
    i) Theca luteum cyst –> occur secondary to conditions which cause high levels of hCG (e.g. multiple pregnancies, trophoblastic disease)

 

b) Benign Neoplastic Cysts

  • Epithelial ➔ This is the most common type (60%) of benig novarian tumours, including:
    i) Serous cystadenoma –> most common in women age 40-50yrs
    ii) Mucinous cystadenoma –> can be huge (secrete mucus which can cause pseudomyxoma peritonei)

 

  • Germ cell tumours  ➔ This is a proliferation of the germ cells, which are seen in younger women
    i) Dermoid cysts -> most common in young women, may contain differentiated tissues (e.g. hair, teeth, fat) which originate from different embryological layers like the ectoderm.
    – Contains a Rokitansky protuberance where the skin and hair is often found

 

  • Sex chord stromal tumour:
    i) Fibroma –> may present with Meig’s syndrome (ovarian tumour + ascites + pleural effusion)
    ii) Sertoli-Leydig cell tumour –> secretes androgens which leads to masculinization

 

  • Endometrioma ➔ A cyst which develops in individuals with endometriosis
    – Also known as ‘chocolate cysts’ because of their brown appearancec) Malignant Neoplastic Cysts

c) Malignant Neoplastic Cysts

  • Epithelial ➔ This is the most common type representing 90% of primary ovarian cancers, including:
    i) Serous cystadenocarcinoma –> a malignant proliferation of the serous cells
    ii) Mucinous cystadenocarcinoma –> a malignant proliferation of the mucus producing cells

 

  • Germ cell tumours ➔ These are most common in younger women and are typically hormone secreting
    i) Yolk sac tumours –> proliferation of cells that resemble yolk sac elements + secretes AFP
    ii) Dysgerminomas –> most common type of germ cell tumour + secretes LDH
    iii) Non-gestational choriocarcinoma –> proliferation of cyto/syncitiotrophoblasts +secretes hCG

 

  • Sex-chord stromal tumour:

i) Granulosa cell tumour –> Malignant proliferation of granulosa cells which is oestrogen secreting

 

  • Metastatic ➔
    This is a metastatic lesion which occurs in the ovaries
    – Usually due to breast, endometrial or GI tumours (in this case called a Krukenberg tumour)
  • Ovarian Cancer (Malignant)

This is a malignant proliferation of cells originating from one of the cell types of the ovary.
– It is usually seen in postmenopausal women around 60 years and is often diagnosed quite late.

Risk factors:
Age, high number of ovulatory cycles (nulliparity, early menarche, late menopause), HRT
– BRCA1 or 2 genes, Lynch syndrome

Symptoms
– Any of these should prompt suspicion of ovarian cancer:
– Abdominal distension (bloating)
– Pelvic or abdominal pain
– Early satiety or loss of appetite
– Increased urinary urgency and/or frequency
– Women >50yrs with IBS symptoms

 

Diagnosis (NICE1):
– At GP: 1st is CA-125 –> if >35IU/ml perform transvaginal ultrasound scan
– If USS appearance suggestive of cancer urgent 2-week referral to gynaecology
– Women who have ascites or pelvic/abdominal mass should get 2-week referral ASAP (without scan)

 

– At gynaecology:
– In women <40yrs, measure AFP and beta-hCG (to check for germ cell tumours)
– Calculate the risk of malignancy index (RMI) which gives you indication of the malignancy risk.

– RMI = Ultrasound score x Menopausal status x CA-125 level

– Menopausal status is scored out of 3
    – Premenopausal = 1
    – Post-menopausal = 3

– Ultrasound scored out of 3
    – 0 features = 1
      1 feature = 1
      2+features = 3

 

– Worrying features include:
Multilocular
Bilateral
SolidAreas
Ascites
Abdominal Masses

Management – If RMI of 250+ refer to specialist MDT team. Do CT CAP for staging of disease.

– If stage 1 ➔ debulking surgery = full hysterectomy + removal of omentum (site of usual metastasis)
– If stage 2/3 ➔ 1st is chemotherapy (cisplatin + taxol) follow by debulking surgery, then chemo again
– PARP inhibitor (Olapurib) ➔ prevents DNA repair mechanisms so the cancerous cells which already have bad DNA repair are futile and die

 

  •  Ovarian Cysts (Benign)

This refers to benign masses which can be fluid filled found on the ovaries.
– Many of these are asymptomatic but can give very similar symptoms to ovarian cancer.
– Can have acute complications –> rupture, haemorrhage, torsion, infection

 

Diagnosis (RCOG2)
– uses the same tests as for ovarian cancer: USS and CA-125 used to calculate RMI
– If premenopausal woman has simple cyst on US –> CA-125 is not needed
– This is because CA-125 can give false positives as it is raised in fibroids, pelvic infection, endometriosis
– If postmenopausal, there is a greater risk of malignancy so both CA-125 and USS are always carried out

Management (RCOG2 guidelines):
– If RMI indicates high risk of malignancy, management is as ovarian cancer (above)

– Premenopausal:
– Small (<50mm) cysts –> no follow-up (most likely functional cysts which usually self-resolve) – Large (>50-70mm) simple cysts –> yearly follow-up
– Very large (>70mm) simple cysts –> further imaging (MRI) or surgical intervention
– Cysts that persist or increase in size –> surgical intervention (cystectomy or oophorectomy)

 

– Post-menopausal (RCOG3 guidelines):
– If asymptomatic, simple and <5cm –> Reassess the cyst in 4-6 months (CA-125+ TVUS)
– If symptomatic, non-simple or >5cm –> Surgical removal using laparoscopic bilateral laparoscopic salpingo-oopherectomy

 

 

  • Ovarian Torsion

This is when the ovary twists on its supporting ligaments. It is a gynaecological emergency as it can cut of the blood supply to the ovary, resulting in ischaemia

Risk factors:
Ovarian cysts (especially dermoid cyst/PCOS), ovulation induction

Symptoms:
Sudden onset of sharp, colicky, unilateral lower quadrant abdominal pain
– Nausea + Vomiting
– May also be a low-grade pyrexia and sinus tachycardia

Tests:
Pelvic ultrasound is used –> unilateral ovarian enlargement, oedema, ‘whirlpool’ sign – Laparoscopy is diagnostic

Treatment:
Emergency laparoscopy to uncoil twisted ovary + fixation

  • Polycystic Ovary Syndrome (PCOS)

This is a syndrome of unknown cause involving hormonal abnormalities and ovarian dysfunction. The key hormonal abnormalities in PCOS include:
i) Insulin resistance resulting in hyperinsulinemia
ii) Increased androgens –> hyperinsulinemia or increased LH production by the anterior pituitary gland
– This leads to excessive androgen production by theca cells of the ovaries.
– In addition, hyperinsulinemia leads to reduced production of sex-hormone binding globulin in the liver
– This means there are higher levels of free testosterone.
– High androgens stop follicle development and ovulation. Follicles remain in the ovaries as multiple cysts.

Symptoms:
– Due to anovulation –> oligomenorrhoea, subfertility
– Due to excessive circulating androgens –> hirsutism and acne
– Due to insulin resistance –> weight gain/difficulty losing weight – May also cause psychological problems like depression

Complications:
– Increased risk of T2DM, HTN and cardiovascular disease
– Increased risk of endometrial cancer due to anovulatory cycles:
– If ovulation does not occur, oestrogen production by the ovary remains high. High unopposed oestrogen levels can lead to hyperplasia of the endometrium.

Tests:
– Blood tests –> High testosterone, Low SHBG, High LH, Normal FSH
– Impaired glucose tolerance test
– Ultrasound –> polycystic ovaries are those with 12+
follicles or increased volume >10cm3

Diagnosis – PCOS should be diagnosed according to the Rotterdam criteria4 – diagnosed PCOS if 2/3 of:
i) Polycystic ovaries on USS ii) Oligo or anovulation iii) Clinical/biochemical signs of hyperandrogenism

Management (NICE CKS5):
– For all symptoms –> weight loss reduces hyperinsulinism + hyperandrogenism
– This helps to restore menstrual regularity, improve fertility.

 

Oligomenorrhoea/ amenorrhoea

If <1 period, every 3 months:
– Give medroxyprogesterone for 14d to induce a bleed
– Refer for TVUS to assess endometrial thickness (to check for hyperplasia/cancer)

 

If the endometrium is normal, give treatment to prevent endometrial hyperplasia. Options include:
– Cyclical progesterone (e.g. medroxyprogesterone for 14d every 1-3 months), COCP, IUS

Hirsutism

– 1st line = COCP (also helps to stop acne) + advice on hair removal methods
– Topical eflornithine is an option for facial hirsutism

Subfertility

– Refer to specialist for fertility treatment

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