Disorders of the Ovary ppt

Ovarian Disorders: Benign

• Follicular Cyst (Functional Cyst): Most common ovarian cyst in reproductive-aged women. Occurs when a follicle persists (doesn't ovulate) or an immature follicle fails to degenerate.

  • Symptoms: Mostly asymptomatic, larger cysts can cause pelvic heaviness and dull pain. Delayed menses followed by heavy bleeding can occur if estrogen production from the follicle continues. Severe pain may indicate hemorrhage, rupture, or torsion.
  • Diagnosis: Pelvic exam, transvaginal ultrasound (TUS).
  • Management: Expectant for asymptomatic, simple cysts. Follow-up exam and ultrasound in 6-12 weeks. Oral contraceptives can be helpful to reduce cyst development but are not effective for reducing the size of an existing cyst. Surgery is indicated for acute pain suggestive of torsion or suspicion of malignancy.

• Corpus Luteum Cyst (Functional Cyst): Results from bleeding within a follicle after ovulation. Can be associated with normal endocrine function or prolonged progesterone secretion.

  • Complications: Acute pain and rupture with intraperitoneal bleeding.

• Theca Lutein Cysts (Functional): Almost always bilateral and can be massive (20-30 cm). Develop due to prolonged or excessive ovarian stimulation from endogenous or exogenous gonadotropins (Gn).

  • Important: The large ovaries can lead to ascites (fluid accumulation in the abdomen) and hemoconcentration (increased blood thickness), which increases the risk of clotting.

• Cystadenoma (Serous or Mucinous): Benign tumor of ovarian surface epithelium. Lined by simple epithelium that can be serous or mucinous.

  • Serous cystadenoma: Filled with pale yellow serous fluid, usually unilocular (single chamber).
  • Mucinous cystadenoma: Filled with sticky mucin, typically multiloculated (multiple chambers). Can be very large (over 20 cm), the largest of all ovarian tumors.

• Tubo-ovarian Abscess (TOA): Infectious disorder of the upper genital tract (pelvic inflammatory disease, PID). Results in an inflammatory mass involving the fallopian tube and ovary.

  • Incidence: Often bilateral due to ascending infection.
  • Symptoms/Complications: Symptoms of PID, adnexal pain and mass. Can become a surgical emergency if sepsis or rupture occurs. Chronic complications include tubal occlusion, infertility, ectopic pregnancy, and chronic pelvic pain due to adhesions.
  • Diagnosis: Pelvic exam and TUS.
  • Management: Inpatient intravenous antibiotics with coverage for gonorrhea, chlamydia, and anaerobes. Laparoscopy is not indicated unless there is no improvement or worsening symptoms suspicious for rupture or if the diagnosis is in question.

• Endometrioma (Chocolate Cyst): Ovarian cyst arising from ectopic endometrial tissue within the ovary. Contain thick, brown, tar-like fluid. Often densely adherent to surrounding structures.

  • Symptoms/Complications: Symptoms of endometriosis, pelvic pain, dysmenorrhea, dyspareunia.
  • Diagnosis: TUS with characteristic internal echogenicity.
  • Management: Surgical intervention for pain relief, exclusion of malignancy, and infertility. Conservative surgery includes cystectomy at laparoscopy or laparotomy. Definitive surgery involves oophorectomy.

• Mature Cystic Teratoma (Dermoid): Benign neoplasm arising from a single germ cell containing tissue from all three germ layers: ectoderm, mesoderm, and endoderm.

  • Incidence: Most common benign neoplasm in women under 35, including adolescents. 10-15% are bilateral.
  • Symptoms/Complications: Torsion (twisting) with pain in 15%.
  • Diagnosis: Often discovered incidentally on pelvic exam, abdominal X-ray or TUS.
  • Management: Observation is not appropriate. Operative laparoscopy with cystectomy or oophorectomy (conserve ovary if fertility is desired). Avoid spillage of cyst contents to prevent peritonitis. Laparotomy is only indicated if malignancy is suspected.

• Paraovarian Cyst or Fibroid: Simple epithelial-lined cyst (rarely complex) or benign fibroid located adjacent to the ovary, usually within the broad ligament.

• Ovarian (Adnexal) Torsion: Rotation of the ovary or ovary and fallopian tube to a degree that occludes blood supply. Can be partial, intermittent, or complete, resulting in necrosis.

  • Incidence: Most common in reproductive-aged women. Ovaries that are enlarged are more susceptible. Rare in malignancy.
  • Diagnosis: Pelvic exam, TUS with Doppler flow studies.
  • Management: Surgical emergency. Laparoscopy or laparotomy.

Ovarian Disorders: Malignant

• History Suggesting a Malignant Ovarian Mass: Abdominal pain, dyspepsia, bloating, increased abdominal girth, early satiety, weight loss, fatigue, dyspnea (due to ascites or pleural effusion). Important to note the history of any benign cysts, as malignant masses may present similarly.

• Physical Exam Findings Suggesting a Malignant Ovarian Mass: Weight loss, pleural effusion, jaundice, ascites, abdominal distention, nodular or fixed pelvic mass, possibly very large.

• Ultrasound Findings Suggesting a Malignant Ovarian Mass: Thick septations, papillary projections into the cyst lumen, intramural nodule, cystic and solid components, increased overall ovarian volume, increased Doppler blood flow.

• When to Refer to a Gynecologic Oncologist: Any woman with a pelvic mass and any of the following characteristics should be referred:

  • Elevated CA 125 level: >35 in postmenopausal women, >200 in premenopausal women.

Cancer of the Ovary

• Detection: Most ovarian cancers are detected incidentally on physical exam or during pelvic imaging (ultrasound, CT, MRI).

• Differential Diagnosis of a Pelvic Mass: May be gynecologic or non-gynecologic in origin. Consider location of the mass, patient age, and reproductive status:

  • Gynecologic causes: Benign or malignant ovarian lesions, tubal or paratubal processes (hydrosalpinges or ectopic pregnancy), uterine abnormalities (leiomyomas or Mullerian abnormalities).
  • Non-gynecologic causes: Less common. May be related to other systems like the gastrointestinal (GI) or urologic systems, or metastatic cancer (especially breast, colon, gastric).

• Risk factors:

  • Most important independent risk factor: Age. Incidence increases sharply after menopause. Median age of onset is 63.
  • Most important personal risk factor: Strong family history of breast or ovarian cancer.

• Evaluation:

  • Symptoms: Can help refine differential diagnosis.

    • Acute onset of abdominal or pelvic pain may suggest hemorrhagic or bleeding ovarian cyst. Important to assess for pregnancy as ectopic pregnancy is a possibility.
    • Unilateral, intermittent, then acutely worsening pelvic pain may indicate ovarian torsion.
    • Indolent, progressive pelvic pain with fever, chills, vomiting, and vaginal discharge may indicate an infectious etiology like TOA.
    • Acute or chronic dysmenorrhea or pain with intercourse may suggest an endometrioma.

  • Imaging:

    • Transvaginal ultrasound (TUS): Most commonly used. Assess size, composition, laterality, presence of septations, nodules, papillary excrescences, and free fluid in the pelvis. Consider Doppler characteristics.
    • MRI: Not routinely recommended. May be useful for better characterization of origin.
    • CT: Best for detecting abdominal metastatic disease or determining origin.

  • Serum Marker Testing: Used in conjunction with imaging.

    • CA-125: Most commonly used protein associated with epithelial ovarian malignancies. Also expressed at lower levels in non-malignant tissue. Elevation can occur in endometriosis, pregnancy, PID, non-gynecologic cancer. Most useful in postmenopausal women. Elevated in 80% of patients with epithelial ovarian cancer but only 50% with stage 1 disease.

• Utility of CA-125: Not useful as a screening test for ovarian cancer, even in high-risk women. Pelvic ultrasound is also not useful as a screening test. CA-125 can be helpful when used in conjunction with other findings. CA-125 elevation is more likely to indicate malignancy in postmenopausal women. A referral to a gynecologic oncologist should be considered if a postmenopausal woman presents with a mass and elevated CA-125.

• Biomarker Panels: Less useful as an initial assessment tool but may be more appropriate in cases where surgery has been performed to further determine if a gynecologic oncology referral is needed. Many of these tests are still under investigation and their clinical utility is being studied.

• Ovarian Cancer Risk with Family History:

  • For a 35-year-old woman with a single affected family member, the lifetime risk increases from 1.6% to 5%.
  • For a woman with a BRCA1 gene mutation, the lifetime risk of ovarian cancer, fallopian tube cancer, or peritoneal cancer is 41-46% by age 70.

Ovarian Disorders

• Benign Ovarian Disorders: These disorders can be physiologic (functional) or non-functional.
  • Follicular Cyst:
    • Most common cystic structure in normal ovaries
    • Occurs in women of reproductive age (ovulatory).
    • Arises from a persistent unovulated follicle or an immature follicle that fails to undergo atresia.
    • Often asymptomatic, but can cause pelvic heaviness, dull pain, and irregular periods.
    • Management: Expectant (if asymptomatic) or oral contraceptives (if recurring or symptomatic).
  • Corpus Luteum Cyst:
    • Occurs after ovulation due to intrafollicular bleeding.
    • Associated with normal endocrine function or prolonged progesterone secretion.
    • Can cause acute pain and may rupture, leading to bleeding.
  • Theca Lutein Cyst:
    • Typically bilateral.
    • Can grow large (up to 20-30 cm) and are easily identified by ultrasound.
    • Result from prolonged or excessive stimulation of ovaries by hormones (like those used for fertility treatments).
    • Can cause ascites and hemoconcentration.
  • Cystadenoma (Serous or Mucinous):
    • Benign tumor of ovarian surface epithelium.
    • Serous cystadenomas are filled with clear fluid.
    • Mucinous cystadenomas are filled with sticky mucin and tend to be multiloculated.
    • Often asymptomatic, but larger tumors can cause bloating or pelvic pressure.
    • Management: Surgical removal with frozen section for staging (oncologist).
  • Tubo-ovarian Abscess (TOA):
    • Infectious disorder of the upper genital tract.
    • Can be bilateral and present with symptoms of Pelvic Inflammatory Disease (PID), adnexal pain, and mass.
    • Can be a surgical emergency if sepsis or rupture occurs.
    • Management: Inpatient IV antibiotics and laparoscopy (if no improvement or suspicion of rupture).
  • Endometrioma (Chocolate Cyst):
    • Benign mass that occurs from growth of ectopic endometrial tissue within the ovary.
    • Typically contain thick brown fluid and may be adherent to surrounding tissues.
    • Often presents with symptoms of endometriosis like pelvic pain, dysmenorrhea, and dyspareunia.
    • Management: Surgical removal (cystectomy or oophorectomy) for pain relief and preventing malignancy.
  • Mature Cystic Teratoma (Dermoid):
    • Benign tumor that arises from single germ cell containing tissue from all three germ layers (ectoderm, mesoderm, and endoderm).
    • Most common benign tumor in women under 35, including adolescents.
    • Often discovered incidentally on physical exam or imaging.
    • Management: Surgical removal (cystectomy or oophorectomy) with precautions taken to avoid spillage of cyst contents.
  • Paraovarian Cyst:
    • Simple epithelial-lined cyst near the ovary, usually within the broad ligament.
  • Ovarian (Adnexal) Torsion:
    • Rotation of the ovary or ovary and fallopian tube that restricts blood flow.
    • Most common in women of reproductive age who have enlarged ovaries.
    • Can be an emergency.
    • Management: Surgical intervention (laparoscopy or laparotomy) to restore blood flow.

Ovarian Cancer

• Risk Factors:
  • Age: Most important factor, with risk increasing after menopause (~63 years old).
  • Family History: Strong family history of breast or ovarian cancer is a significant risk factor.
• Symptoms:
  • Early Stages: Often asymptomatic.
  • Later Stages: Abdominal pain, bloating, early satiety, weight loss, fatigue, dyspnea.
• Diagnosis:
  • Imaging: Transvaginal ultrasound is the most common, looking for size, composition, laterality, and other features indicative of malignancy.
  • Serum Marker Testing: CA-125 is a protein associated with epithelial ovarian malignancies.
  • Biomarker Panels: Although under investigation, may help determine if further assessment (by gynecologic oncologist) is necessary.
• Management:
  • Referral to Gynecologic Oncologist: Women with a pelvic mass and elevated CA-125 level in postmenopausal women or any woman with symptoms suggestive of malignancy should be referred to a gynecologic oncologist.
• Prognosis:
  • Age, stage of cancer, and underlying health condition play a significant role.
  • Early detection and treatment offer the best chance of survival.

Ovarian Disorders - Important Considerations

• Differential Diagnosis: When encountering a pelvic mass, it's important to consider both gynecologic and non-gynecologic causes (e.g., ectopic pregnancy, endometriosis, fibroids, gastrointestinal conditions, and metastatic cancer).
• Conservative Treatment: For many benign ovarian disorders, expectant management or conservative treatment (e.g., oral contraceptives) may be appropriate. However, regular follow-up and close monitoring are crucial.
• Surgical Intervention: Surgical intervention becomes necessary for certain conditions like TOA, endometriomas, dermoid cysts, and ovarian torsion.
• Importance of Referral: Depending on the findings, referral to specialists (e.g., gynecologic oncologist) may be critical for timely diagnosis and treatment, especially for suspected malignancies.
• Screening: At this time, there are no effective screening methods for routine detection of ovarian cancer. However, understanding risk factors and being aware of symptoms can help with early detection.